Provider Demographics
NPI:1366134744
Name:DAS PURKAYASTHA, SELVI MAHALAKSHMI (DMD)
Entity type:Individual
Prefix:DR
First Name:SELVI
Middle Name:MAHALAKSHMI
Last Name:DAS PURKAYASTHA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W 132ND ST APT 2U
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-3218
Mailing Address - Country:US
Mailing Address - Phone:630-664-9513
Mailing Address - Fax:
Practice Address - Street 1:3439 MCGEHEE RD STE 22B
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-3392
Practice Address - Country:US
Practice Address - Phone:334-284-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.007310-C1122300000X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD007310-C1Medicaid