Basic Information
| Provider Information | |||||||||
| NPI: | 1194053397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THAKKAR | ||||||||
| FirstName: | DIPA | ||||||||
| MiddleName: | SHARMA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7131 S JEFFERY BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606492176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129962000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 770 HOLCOMB BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300761618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782332959 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2009 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 019.028160 | IL | N | Dental Providers | Dentist | 1223G0001X | DN122224 | GA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 019.028160 | 05 | IL | MEDICAID |