Provider Demographics
NPI:1376052043
Name:KOTAK, BHOOMI (DMD)
Entity Type:Individual
Prefix:DR
First Name:BHOOMI
Middle Name:
Last Name:KOTAK
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 1:320 MIDDLESEX AVE UNIT C208
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5084
Mailing Address - Country:US
Mailing Address - Phone:603-930-1124
Mailing Address - Fax:
Practice Address - Street 1:14 MCGRATH HWY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-4505
Practice Address - Country:US
Practice Address - Phone:617-934-2164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18578321223X0400X, 122300000X
IL019031413122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist