Provider Demographics
NPI:1003045675
Name:THACKER, SEJAL (DDS)
Entity Type:Individual
Prefix:
First Name:SEJAL
Middle Name:
Last Name:THACKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 SPRING LANE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107
Mailing Address - Country:US
Mailing Address - Phone:860-206-1205
Mailing Address - Fax:
Practice Address - Street 1:82 SPRING LANE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107
Practice Address - Country:US
Practice Address - Phone:860-206-1205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-04
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0107071223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics