Provider Demographics
NPI:1750621363
Name:BHAUMIK, ABHISHEK
Entity type:Individual
Prefix:
First Name:ABHISHEK
Middle Name:
Last Name:BHAUMIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2244 S BUCKNER BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-8603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2244 S BUCKNER BLVD STE B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-8603
Practice Address - Country:US
Practice Address - Phone:214-381-0663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221145611223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX390200000XMedicaid