Provider Demographics
NPI:1114307584
Name:THANAWALA, VIVEK (DMD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:
Last Name:THANAWALA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 KIMBERLY PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-7225
Mailing Address - Country:US
Mailing Address - Phone:919-478-6353
Mailing Address - Fax:
Practice Address - Street 1:4241 KIMBERLY PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-7225
Practice Address - Country:US
Practice Address - Phone:919-478-6353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30-247901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program