MEDICARE: PARVATHI POKALA DDS INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	40296	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G92041-01	OTHER	CA	DENTICAL IDENTIFICATION

General Provider Information

NPI Number	:	1013190172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARVATHI POKALA DDS INCORPORATED

Provider Business Mailing Address
First Line	:	3737 MORAGA AVE STE B313
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-5481
Country	:	US
Telephone Number	:	858-274-0722
Fax Number	:	858-274-1175

Provider Business Practice Location Address
First Line	:	3737 MORAGA AVE STE B313
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-5481
Country	:	US
Telephone Number	:	858-274-0722
Fax Number	:	858-274-1175

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PARVATHI KOKA POKALA
Credential	:	DDS
Telephone Number	:	858-274-0722

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	12/12/2007

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