Provider Demographics
NPI:1851610869
Name:WEST AVENUE DENTAL PC
Entity Type:Organization
Organization Name:WEST AVENUE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HRISHIKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOGATE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-939-1460
Mailing Address - Street 1:520 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-4034
Mailing Address - Country:US
Mailing Address - Phone:203-939-1460
Mailing Address - Fax:
Practice Address - Street 1:520 WEST AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-4034
Practice Address - Country:US
Practice Address - Phone:203-939-1460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-01
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT100891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1851610869Medicaid