Provider Demographics
NPI:1306414537
Name:PREMA, MUKTI GUNVANT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MUKTI
Middle Name:GUNVANT
Last Name:PREMA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5461 OAK CHASE DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4250
Mailing Address - Country:US
Mailing Address - Phone:615-612-8985
Mailing Address - Fax:
Practice Address - Street 1:2101 BAKER CARTER DR STE 200
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7466
Practice Address - Country:US
Practice Address - Phone:678-661-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1228751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13-3971298OtherNYU LANGONE MEDICAL CENTER