Provider Demographics
NPI:1629140157
Name:VASHI, SURENDRA R (DMD)
Entity Type:Individual
Prefix:DR
First Name:SURENDRA
Middle Name:R
Last Name:VASHI
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 1:57 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2503
Mailing Address - Country:US
Mailing Address - Phone:973-481-3981
Mailing Address - Fax:973-481-1082
Practice Address - Street 1:57 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-2503
Practice Address - Country:US
Practice Address - Phone:973-481-3981
Practice Address - Fax:973-481-1082
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDIO 176191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1168217OtherHORIZON NJ HEALTH
NJ17836OtherAMERIGROUP
NJ336421OtherAMERICHOICE
NJ300133795OtherTAX ID
NJ4634501Medicaid