Provider Demographics
NPI:1093368821
Name:SUKHTANKAR, LAXMI
Entity Type:Individual
Prefix:
First Name:LAXMI
Middle Name:
Last Name:SUKHTANKAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 N LOVINGTON DR APT 103
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-4372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18757 HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:MI
Practice Address - Zip Code:48164-9357
Practice Address - Country:US
Practice Address - Phone:734-753-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-21
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016002301223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty