Healthcare Provider Details

I. General information

NPI: 1265688147
Provider Name (Legal Business Name): RAGINI PORWAL D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 09/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14850 HIGHWAY 4 STE B
DISCOVERY BAY CA
94505-2237
US

IV. Provider business mailing address

330 PARNASSUS AVE APT 307
SAN FRANCISCO CA
94117-3752
US

V. Phone/Fax

Practice location:
  • Phone: 925-634-5353
  • Fax:
Mailing address:
  • Phone: 415-242-5657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number57493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: