Provider Demographics
NPI:1316165160
Name:PHATAK, UDAY BALKRISHNA (DDS)
Entity type:Individual
Prefix:DR
First Name:UDAY
Middle Name:BALKRISHNA
Last Name:PHATAK
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 1:642 N MILWAUKEE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PROSPECT HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60070-2353
Mailing Address - Country:US
Mailing Address - Phone:847-541-0008
Mailing Address - Fax:847-541-0009
Practice Address - Street 1:642 N MILWAUKEE AVE STE A
Practice Address - Street 2:
Practice Address - City:PROSPECT HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60070-2353
Practice Address - Country:US
Practice Address - Phone:847-541-0008
Practice Address - Fax:847-541-0009
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018029122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist