Provider Demographics
NPI:1497840953
Name:DESAI, KETKI B (DDS)
Entity Type:Individual
Prefix:
First Name:KETKI
Middle Name:B
Last Name:DESAI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5212 WEST BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228
Mailing Address - Country:US
Mailing Address - Phone:614-878-3636
Mailing Address - Fax:614-878-6224
Practice Address - Street 1:5212 WEST BROAD STREET
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228
Practice Address - Country:US
Practice Address - Phone:614-878-3636
Practice Address - Fax:614-878-6224
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH188731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0765766Medicaid