Provider Demographics
NPI:1639490808
Name:BHANWATH, RAJIV GOKUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAJIV
Middle Name:GOKUL
Last Name:BHANWATH
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 1:9 AVONWOOD RD
Mailing Address - Street 2:BUILDING B
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2072
Mailing Address - Country:US
Mailing Address - Phone:860-284-4411
Mailing Address - Fax:860-679-9389
Practice Address - Street 1:9 AVONWOOD RD
Practice Address - Street 2:BUILDING B
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-2072
Practice Address - Country:US
Practice Address - Phone:860-284-4411
Practice Address - Fax:860-679-9389
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice