Provider Demographics
NPI:1669518700
Name:BHAKTA, JAGRUTI (DMD)
Entity type:Individual
Prefix:
First Name:JAGRUTI
Middle Name:
Last Name:BHAKTA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 1ST ST APT 16PB
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-8802
Mailing Address - Country:US
Mailing Address - Phone:646-785-9137
Mailing Address - Fax:
Practice Address - Street 1:639 W 173RD ST APT 1A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1426
Practice Address - Country:US
Practice Address - Phone:212-928-4480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051844-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02837956Medicaid