Healthcare Provider Details

I. General information

NPI: 1124645452
Provider Name (Legal Business Name): SAMIR GWALANI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11092 ANDERSON ST
LOMA LINDA CA
92350-1706
US

IV. Provider business mailing address

26385 ORANGE AVE
LOMA LINDA CA
92354-6120
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4000
  • Fax:
Mailing address:
  • Phone: 702-530-3179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS107021
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: