Healthcare Provider Details

I. General information

NPI: 1073112900
Provider Name (Legal Business Name): KRISHNA BHAKTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date: 08/10/2026
Reactivation Date: 08/21/2026

III. Provider practice location address

641 W ROUTE 66 STE E
GLENDORA CA
91740-4153
US

IV. Provider business mailing address

1533 FIRESTONE BLVD
LOS ANGELES CA
90001-3923
US

V. Phone/Fax

Practice location:
  • Phone: 626-346-0069
  • Fax:
Mailing address:
  • Phone: 949-833-2237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113719
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: