Provider Demographics
NPI:1619195138
Name:MUKHATIYAR, SAPAN ANIL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAPAN
Middle Name:ANIL
Last Name:MUKHATIYAR
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 1:5903 ROOSEVELT AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3546
Mailing Address - Country:US
Mailing Address - Phone:718-651-7700
Mailing Address - Fax:
Practice Address - Street 1:5903 ROOSEVELT AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3546
Practice Address - Country:US
Practice Address - Phone:718-651-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0529691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02910263Medicaid