Provider Demographics
NPI:1710059860
Name:RACHA, ERIC BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:BRUCE
Last Name:RACHA
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 1:120 MEMORIAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501
Mailing Address - Country:US
Mailing Address - Phone:315-733-5722
Mailing Address - Fax:315-733-9472
Practice Address - Street 1:120 MEMORIAL PARKWAY
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501
Practice Address - Country:US
Practice Address - Phone:315-733-5722
Practice Address - Fax:315-733-9472
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04217111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01805949Medicaid
NY011218OtherFIDELIS