Provider Demographics
NPI:1003236555
Name:PRAKASH K. UPADHYAYA DDS LTD.
Entity Type:Organization
Organization Name:PRAKASH K. UPADHYAYA DDS LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAKASH
Authorized Official - Middle Name:K
Authorized Official - Last Name:UPADHYAYA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-865-2400
Mailing Address - Street 1:2400 W ROOSEVELT RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-3880
Mailing Address - Country:US
Mailing Address - Phone:708-865-2400
Mailing Address - Fax:
Practice Address - Street 1:2400 W ROOSEVELT RD
Practice Address - Street 2:SUITE #1
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3880
Practice Address - Country:US
Practice Address - Phone:708-865-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAKASH K. UPADHYAYA DDS LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019015678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty