Provider Demographics
NPI:1235802604
Name:VAGISHA, KHUSHBOO (DMD)
Entity Type:Individual
Prefix:
First Name:KHUSHBOO
Middle Name:
Last Name:VAGISHA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 ALLEGHENY DR
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-4203
Mailing Address - Country:US
Mailing Address - Phone:413-362-2751
Mailing Address - Fax:
Practice Address - Street 1:1312 CENTENNIAL AVE STE 11
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-4324
Practice Address - Country:US
Practice Address - Phone:732-981-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI028115001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice