Basic Information
| Provider Information | |||||||||
| NPI: | 1124403407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BHATT | ||||||||
| FirstName: | SANJAY | ||||||||
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| Credential: | DDS, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 883 NE MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296812051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647561060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 883 NE MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296812051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647561060 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2015 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | ETN338 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223S0112X | 10265 | SC | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | ETN338 | 01 | TX | TEXAS STATE BOARD OF DENTAL EXAMINERS | OTHER |