Provider Demographics
NPI:1104204866
Name:DESAI, ROSHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSHAN
Middle Name:
Last Name:DESAI
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 1:25 WOODRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1143
Mailing Address - Country:US
Mailing Address - Phone:718-920-4321
Mailing Address - Fax:
Practice Address - Street 1:25 WOODRIDGE LN
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1143
Practice Address - Country:US
Practice Address - Phone:718-920-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0588501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice