Provider Demographics
NPI:1720513625
Name:BUKHARI, JALAL UD-DIN
Entity type:Individual
Prefix:
First Name:JALAL
Middle Name:UD-DIN
Last Name:BUKHARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 BALSAM DR
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-2051
Mailing Address - Country:US
Mailing Address - Phone:631-355-9371
Mailing Address - Fax:
Practice Address - Street 1:53 BETTY ANN DR
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1043
Practice Address - Country:US
Practice Address - Phone:631-355-9371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0608121223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA97664419F45226Medicaid