Provider Demographics
NPI:1295200798
Name:JETHANI, MOHIT SATISH (DMD)
Entity Type:Individual
Prefix:
First Name:MOHIT
Middle Name:SATISH
Last Name:JETHANI
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 1:2802 E LINCOLN ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6153
Mailing Address - Country:US
Mailing Address - Phone:424-325-9393
Mailing Address - Fax:
Practice Address - Street 1:411 KEOKUK ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-1726
Practice Address - Country:US
Practice Address - Phone:217-732-8818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2023-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190337921223G0001X
MADN1858142122300000X
NH046981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist