MEDICARE: PRAMUKHASHISH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	22DI02033900	NJ

General Provider Information

NPI Number	:	1518024413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAMUKHASHISH, LLC

Provider Business Mailing Address
First Line	:	1503 SAINT GEORGES AVE
Second Line	:	SUITE 102
City	:	COLONIA
State	:	NJ
Zip	:	07067-3425
Country	:	US
Telephone Number	:	732-382-4104
Fax Number	:	732-388-6078

Provider Business Practice Location Address
First Line	:	1503 SAINT GEORGES AVE
Second Line	:	SUITE 102
City	:	COLONIA
State	:	NJ
Zip	:	07067-3425
Country	:	US
Telephone Number	:	732-382-4104
Fax Number	:	732-388-6078

Authorized Official
Title or Position	:	SINGLE-MEMBER OWNER
Name	:	DR. KAVITA PANKAJ PATEL
Credential	:	D.D.S.
Telephone Number	:	732-382-4104

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	08/22/2020

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