Provider Demographics
NPI:1750428009
Name:PURI, RAJIV (DDS)
Entity type:Individual
Prefix:DR
First Name:RAJIV
Middle Name:
Last Name:PURI
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 1:150 E IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-2024
Mailing Address - Country:US
Mailing Address - Phone:630-616-1020
Mailing Address - Fax:630-616-1725
Practice Address - Street 1:150 E IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-2024
Practice Address - Country:US
Practice Address - Phone:630-616-1020
Practice Address - Fax:630-616-1725
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist