Provider Demographics
NPI:1760846711
Name:UPADHYAYA, BHOOMI (DDS)
Entity Type:Individual
Prefix:
First Name:BHOOMI
Middle Name:
Last Name:UPADHYAYA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 BYRON PL
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-3809
Mailing Address - Country:US
Mailing Address - Phone:973-513-2830
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PARK DR STE 16
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-1966
Practice Address - Country:US
Practice Address - Phone:845-535-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY059201-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program