Provider Demographics
NPI:1861663569
Name:SHETTY, SUDHAKAR Y (DDS)
Entity Type:Individual
Prefix:
First Name:SUDHAKAR
Middle Name:Y
Last Name:SHETTY
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 1:8713 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-2037
Mailing Address - Country:US
Mailing Address - Phone:718-847-8023
Mailing Address - Fax:718-847-2009
Practice Address - Street 1:8713 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2037
Practice Address - Country:US
Practice Address - Phone:718-847-8023
Practice Address - Fax:718-847-2009
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0349121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00461041Medicaid