Healthcare Provider Details

I. General information

NPI: 1326445461
Provider Name (Legal Business Name): RANJIVENDRA NATH DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

766 N LAKE AVE
PASADENA CA
91104-4557
US

IV. Provider business mailing address

766 N LAKE AVE
PASADENA CA
91104-4557
US

V. Phone/Fax

Practice location:
  • Phone: 626-808-1717
  • Fax: 626-808-1719
Mailing address:
  • Phone: 626-808-1717
  • Fax: 626-808-1719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number46304
License Number StateCA

VIII. Authorized Official

Name: DR. RANJIVENDRA NATH
Title or Position: PRESIDENT
Credential: DDS
Phone: 626-808-1717