Provider Demographics
NPI:1265537146
Name:TIRTHA, RAJIVA (DDS)
Entity type:Individual
Prefix:
First Name:RAJIVA
Middle Name:
Last Name:TIRTHA
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:PO BOX 90459
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-0459
Mailing Address - Country:US
Mailing Address - Phone:810-744-0433
Mailing Address - Fax:810-744-2257
Practice Address - Street 1:1140 S BELSAY RD
Practice Address - Street 2:SUITE A
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1909
Practice Address - Country:US
Practice Address - Phone:810-744-0433
Practice Address - Fax:810-744-2257
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010135441223G0001X
FLDN97431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice