Healthcare Provider Details

I. General information

NPI: 1720196173
Provider Name (Legal Business Name): PAVITHRA SHETTY THANKACHEN D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. PAVITHRA G SHETTY

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 EAST COAST HWY SUITE 220
CORONA DEL MAR CA
92625-3421
US

IV. Provider business mailing address

2131 EAST COAST HWY SUITE 220
CORONA DEL MAR CA
92625-3421
US

V. Phone/Fax

Practice location:
  • Phone: 949-644-1001
  • Fax:
Mailing address:
  • Phone: 949-644-1001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number51522
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0518561
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number51522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: