Provider Demographics
NPI:1528156593
Name:AMIN, PRADYUMN N (DDS PC)
Entity type:Individual
Prefix:MR
First Name:PRADYUMN
Middle Name:N
Last Name:AMIN
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 WEST SIDE MALL
Mailing Address - Street 2:SUITE 221 OFFICE BLDG
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704
Mailing Address - Country:US
Mailing Address - Phone:570-288-8456
Mailing Address - Fax:
Practice Address - Street 1:250 WEST SIDE MALL
Practice Address - Street 2:SUITE 221 OFFICE BLDG
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704
Practice Address - Country:US
Practice Address - Phone:570-288-8456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020941L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice