Provider Demographics
NPI:1497138549
Name:BRAHMBHATT, RAJ (DDS)
Entity Type:Individual
Prefix:
First Name:RAJ
Middle Name:
Last Name:BRAHMBHATT
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 1:4375 N VANTAGE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4982
Mailing Address - Country:US
Mailing Address - Phone:479-445-6335
Mailing Address - Fax:479-301-2878
Practice Address - Street 1:3533 N SHILOH DR
Practice Address - Street 2:SUITE 3
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5359
Practice Address - Country:US
Practice Address - Phone:479-445-6335
Practice Address - Fax:479-301-2878
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR40631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice