Basic Information
| Provider Information | |||||||||
| NPI: | 1811364656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESAI | ||||||||
| FirstName: | KAVITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PATEL | ||||||||
| OtherFirstName: | KAVITA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8268 164TH ST | ||||||||
| Address2: | DENTAL CLINIC | ||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114321104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188833000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8268 164TH ST | ||||||||
| Address2: | DENTAL CLINIC | ||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114321104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188833000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2015 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 058773 | NY | N | Dental Providers | Dentist | General Practice | 122300000X | 058773 | NY | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 058773 | 01 | NY | LICENSE | OTHER |