Provider Demographics
NPI:1487942777
Name:BACHALI, SARATH N (DMD)
Entity type:Individual
Prefix:DR
First Name:SARATH
Middle Name:N
Last Name:BACHALI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-4788
Mailing Address - Country:US
Mailing Address - Phone:740-370-4234
Mailing Address - Fax:
Practice Address - Street 1:621 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4788
Practice Address - Country:US
Practice Address - Phone:740-370-4234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9096122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100172380Medicaid