Provider Demographics
NPI:1932662590
Name:WAGH, ANIRUDDHA (DDS)
Entity Type:Individual
Prefix:
First Name:ANIRUDDHA
Middle Name:
Last Name:WAGH
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 1:74 BLUE JAY WAY
Mailing Address - Street 2:
Mailing Address - City:REXFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12148-1334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5855 E STILL CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3631
Practice Address - Country:US
Practice Address - Phone:408-248-8107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty