Provider Demographics
NPI:1023495348
Name:GORUKANTI, NIKHILESH RAO (DMD)
Entity type:Individual
Prefix:
First Name:NIKHILESH
Middle Name:RAO
Last Name:GORUKANTI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 HARRISON AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1857
Mailing Address - Country:US
Mailing Address - Phone:908-698-3206
Mailing Address - Fax:
Practice Address - Street 1:594 CENTRE ST APT 1
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2560
Practice Address - Country:US
Practice Address - Phone:617-522-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18568691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice