Provider Demographics
NPI:1285912410
Name:PRADHAN-PECK, SUJATA
Entity type:Individual
Prefix:
First Name:SUJATA
Middle Name:
Last Name:PRADHAN-PECK
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 1:24 GRASSY PLAIN ST
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-1700
Mailing Address - Country:US
Mailing Address - Phone:203-616-5786
Mailing Address - Fax:
Practice Address - Street 1:24 GRASSY PLAIN ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-1700
Practice Address - Country:US
Practice Address - Phone:203-616-5786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028782122300000X
CT010774122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist