Provider Demographics
NPI:1760880355
Name:KHANDELWAL, NAMITA (BDS, MS)
Entity Type:Individual
Prefix:
First Name:NAMITA
Middle Name:
Last Name:KHANDELWAL
Suffix:
Gender:F
Credentials:BDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2656
Practice Address - Country:US
Practice Address - Phone:860-679-3710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-12
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEFDN51223P0300X
CT123661223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1366656100OtherNPI