Provider Demographics
NPI:1093703936
Name:KOTHARI, JAGDISH R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAGDISH
Middle Name:R
Last Name:KOTHARI
Suffix:
Gender:M
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:PO BOX 8078
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13505-8078
Mailing Address - Country:US
Mailing Address - Phone:315-735-7278
Mailing Address - Fax:
Practice Address - Street 1:1900 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5635
Practice Address - Country:US
Practice Address - Phone:315-735-7278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034554122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist