Provider Demographics
NPI:1508905696
Name:PATHARE, PRAKASH S (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRAKASH
Middle Name:S
Last Name:PATHARE
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 1:175 MAXWELL RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110
Mailing Address - Country:US
Mailing Address - Phone:518-786-6282
Mailing Address - Fax:518-783-8259
Practice Address - Street 1:175 MAXWELL RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-786-6282
Practice Address - Fax:518-783-8259
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00655174Medicaid