Provider Demographics
NPI:1396890216
Name:VADAKKEPULLARATT, VIJAYA L (DMD)
Entity type:Individual
Prefix:MRS
First Name:VIJAYA
Middle Name:L
Last Name:VADAKKEPULLARATT
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 1:14215 FRANKLIN AVENUE SUITE #1H
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:718-539-1621
Mailing Address - Fax:718-539-1621
Practice Address - Street 1:14215 FRANKLIN AVENUE SUITE #1H
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-539-1621
Practice Address - Fax:718-539-1621
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0418571122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01101179Medicaid
NY0418571OtherNEW YORK STATE LICENSE