Provider Demographics
NPI:1801275086
Name:GOSAR, SHRUSHTI
Entity type:Individual
Prefix:
First Name:SHRUSHTI
Middle Name:
Last Name:GOSAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 CONNECTICUT BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3013
Mailing Address - Country:US
Mailing Address - Phone:860-610-6353
Mailing Address - Fax:860-528-2353
Practice Address - Street 1:94 CONNECTICUT BLVD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3013
Practice Address - Country:US
Practice Address - Phone:860-610-6353
Practice Address - Fax:860-528-2353
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040552122300000X
CT11710122300000X
MADN1857432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist