Healthcare Provider Details

I. General information

NPI: 1336696426
Provider Name (Legal Business Name): DMITRIY PIVNIK DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 10/18/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18455 TECHNOLOGY DR
MORGAN HILL CA
95037-2822
US

IV. Provider business mailing address

18455 TECHNOLOGY DR
MORGAN HILL CA
95037-2822
US

V. Phone/Fax

Practice location:
  • Phone: 916-783-5239
  • Fax:
Mailing address:
  • Phone: 562-577-5641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number100181
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1275991721
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name: DMITRIY PIVNIK
Title or Position: OFFICER
Credential: D.D.S
Phone: 415-412-3158