Healthcare Provider Details

I. General information

NPI: 1659545374
Provider Name (Legal Business Name): IMAGE DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7557 EL CAJON BLVD SUITE A
LA MESA CA
91942-7823
US

IV. Provider business mailing address

7557 EL CAJON BLVD SUITE A
LA MESA CA
91942-7823
US

V. Phone/Fax

Practice location:
  • Phone: 619-469-4144
  • Fax: 619-469-4143
Mailing address:
  • Phone: 619-469-4144
  • Fax: 619-469-4142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number51847
License Number StateCA

VIII. Authorized Official

Name: DR. PRASHANT RAMAN PATEL
Title or Position: OWNER
Credential: DDS
Phone: 619-469-4144