=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528345188
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RISHI A KOTHARI D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2011
-----------------------------------------------------
Last Update Date | 04/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 N BROADWAY SUITE 104
-----------------------------------------------------
City | SLEEPY HOLLOW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10591-2670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-332-0900
-----------------------------------------------------
Fax | 914-214-5308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 N BROADWAY SUITE 104
-----------------------------------------------------
City | SLEEPY HOLLOW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10591-2670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-332-0900
-----------------------------------------------------
Fax | 914-214-5308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 055809
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------