Provider Demographics
NPI:1417151945
Name:DAVITIASHVILI, NODARI (DDS)
Entity Type:Individual
Prefix:DR
First Name:NODARI
Middle Name:
Last Name:DAVITIASHVILI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:NODARI
Other - Middle Name:
Other - Last Name:DAVITI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3902 SEDGWICK AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4460
Mailing Address - Country:US
Mailing Address - Phone:917-495-1000
Mailing Address - Fax:
Practice Address - Street 1:3902 SEDGWICK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-4460
Practice Address - Country:US
Practice Address - Phone:917-495-1000
Practice Address - Fax:917-495-1000
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0483091122300000X
CT0109211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01975048Medicaid