Provider Demographics
NPI:1750721544
Name:SONI, DIVYANSHU (DMD)
Entity type:Individual
Prefix:
First Name:DIVYANSHU
Middle Name:
Last Name:SONI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-2213
Mailing Address - Country:US
Mailing Address - Phone:978-632-5659
Mailing Address - Fax:
Practice Address - Street 1:49 CROSS ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440
Practice Address - Country:US
Practice Address - Phone:978-632-5659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18564821223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004011136Medicaid
CT004011367Medicaid