Provider Demographics
NPI:1578983565
Name:JAIN, VIKAS RAJA (DMD)
Entity Type:Individual
Prefix:
First Name:VIKAS
Middle Name:RAJA
Last Name:JAIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 S PENDLETON ST
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-3527
Mailing Address - Country:US
Mailing Address - Phone:864-855-6563
Mailing Address - Fax:864-855-6530
Practice Address - Street 1:807 S PENDLETON ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-3527
Practice Address - Country:US
Practice Address - Phone:864-855-6563
Practice Address - Fax:864-855-6530
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist