Healthcare Provider Details

I. General information

NPI: 1689349763
Provider Name (Legal Business Name): KISHEN D GODHIA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WATERWORKS WAY STE 260
IRVINE CA
92618-3169
US

IV. Provider business mailing address

113 WATERWORKS WAY STE 260
IRVINE CA
92618-3169
US

V. Phone/Fax

Practice location:
  • Phone: 858-248-7013
  • Fax:
Mailing address:
  • Phone: 858-248-7013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS106452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: