Provider Demographics
NPI:1821625377
Name:MAHADEVIA, ROHAN JAGRUT
Entity Type:Individual
Prefix:
First Name:ROHAN
Middle Name:JAGRUT
Last Name:MAHADEVIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TUSKEGEE BLVD
Mailing Address - Street 2:DOVER AFB
Mailing Address - City:APO
Mailing Address - State:AA
Mailing Address - Zip Code:19902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:
Practice Address - City:DOVER AFB
Practice Address - State:DE
Practice Address - Zip Code:19902
Practice Address - Country:US
Practice Address - Phone:302-730-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042895122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty