MEDICARE: DR. SANJAY M MALLYA B.D.S.

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	1223X0008X	Oral and Maxillofacial Radiology Dentistry	9026	CT
2	1223X0008X	Oral and Maxillofacial Radiology Dentistry	SP-251	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538158043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANJAY M MALLYA B.D.S.

Provider Business Mailing Address
First Line	:	P.O. BOX 951668
Second Line	:	CHS 10-165
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1668
Country	:	US
Telephone Number	:	860-679-2453
Fax Number	:	860-679-2756

Provider Business Practice Location Address
First Line	:	10833 LE CONTE AVE
Second Line	:	CHS 10-165
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1668
Country	:	US
Telephone Number	:	310-825-5634
Fax Number	:	310-206-2748

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	03/02/2010

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Directions to “ DR. SANJAY M MALLYA B.D.S.” Practice Location

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