Provider Demographics
NPI:1942041306
Name:KETKAR, VIRAJ MOHAN (DDS)
Entity type:Individual
Prefix:DR
First Name:VIRAJ
Middle Name:MOHAN
Last Name:KETKAR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SAINT FRANCIS PL APT 2301
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-1347
Mailing Address - Country:US
Mailing Address - Phone:415-283-7089
Mailing Address - Fax:
Practice Address - Street 1:5240 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7372
Practice Address - Country:US
Practice Address - Phone:219-873-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-01
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN12014534A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program