Provider Demographics
NPI:1629824214
Name:BHAKTA, NIYATI (DDS)
Entity type:Individual
Prefix:
First Name:NIYATI
Middle Name:
Last Name:BHAKTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1687 REMBRANDT DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-6829
Mailing Address - Country:US
Mailing Address - Phone:636-696-6414
Mailing Address - Fax:
Practice Address - Street 1:18340 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2910
Practice Address - Country:US
Practice Address - Phone:708-799-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0353331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice