Provider Demographics
NPI:1457442014
Name:MAHADIK, VILAS BABURAO (BDSMDS)
Entity Type:Individual
Prefix:
First Name:VILAS
Middle Name:BABURAO
Last Name:MAHADIK
Suffix:
Gender:M
Credentials:BDSMDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 78TH ST
Mailing Address - Street 2:APARTMENT#418
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1950
Mailing Address - Country:US
Mailing Address - Phone:718-426-5561
Mailing Address - Fax:
Practice Address - Street 1:235 WYCKOFF AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-5303
Practice Address - Country:US
Practice Address - Phone:718-418-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038008122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00806193Medicaid
NY75312OtherCARE PLUS
NY9178107OtherDORAL