Provider Demographics
NPI:1225489859
Name:CHALIAWALA, MAYANK
Entity Type:Individual
Prefix:
First Name:MAYANK
Middle Name:
Last Name:CHALIAWALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 HARTFORD TPKE APT 593
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-9405
Mailing Address - Country:US
Mailing Address - Phone:201-850-3567
Mailing Address - Fax:
Practice Address - Street 1:35 TALCOTTVILLE RD STE 21
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5261
Practice Address - Country:US
Practice Address - Phone:860-896-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2.0116511223G0001X
CT116511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice