Provider Demographics
NPI:1508559303
Name:THAKKAR, RADHIKA (BDS, MPH)
Entity type:Individual
Prefix:DR
First Name:RADHIKA
Middle Name:
Last Name:THAKKAR
Suffix:
Gender:F
Credentials:BDS, MPH
Other - Prefix:DR
Other - First Name:RADHIKA
Other - Middle Name:RAMESHBHAI
Other - Last Name:THAKKAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BDS, MPH
Mailing Address - Street 1:22 WEBSTER MANOR DR APT 4
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2011
Mailing Address - Country:US
Mailing Address - Phone:201-289-3974
Mailing Address - Fax:
Practice Address - Street 1:625 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2913
Practice Address - Country:US
Practice Address - Phone:585-275-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0639761223G0001X, 122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY063976OtherNY DENTIST LICENSE