Provider Demographics
NPI:1376677633
Name:RENJEN, RAHUL (DDS)
Entity Type:Individual
Prefix:
First Name:RAHUL
Middle Name:
Last Name:RENJEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 PENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1736
Mailing Address - Country:US
Mailing Address - Phone:585-432-0455
Mailing Address - Fax:
Practice Address - Street 1:103 WHITE PARK RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2258
Practice Address - Country:US
Practice Address - Phone:716-523-1885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051708-11223X0400X
PADS0371131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02898355Medicaid
PA1020266440001Medicaid