Provider Demographics
NPI:1720781438
Name:KHADSE, PRAJKTA
Entity type:Individual
Prefix:
First Name:PRAJKTA
Middle Name:
Last Name:KHADSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ALLING ST # 25
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-5376
Mailing Address - Country:US
Mailing Address - Phone:917-415-2729
Mailing Address - Fax:
Practice Address - Street 1:9 ALLING ST # 25
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-5376
Practice Address - Country:US
Practice Address - Phone:917-415-2729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2024-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI030544001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program