Healthcare Provider Details

I. General information

NPI: 1275241028
Provider Name (Legal Business Name): VIMALA VONTELA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 E CENTER ST
MANTECA CA
95336-4719
US

IV. Provider business mailing address

527 E CENTER ST
MANTECA CA
95336-4719
US

V. Phone/Fax

Practice location:
  • Phone: 209-823-7655
  • Fax: 209-823-7656
Mailing address:
  • Phone: 209-823-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. VIMALA VONTELA
Title or Position: PRESIDENT
Credential: DDS
Phone: 209-823-7655