Healthcare Provider Details

I. General information

NPI: 1154832111
Provider Name (Legal Business Name): SITAL MANDALIA DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 N ROSE DR
PLACENTIA CA
92870-7520
US

IV. Provider business mailing address

724 N ROSE DR
PLACENTIA CA
92870-7520
US

V. Phone/Fax

Practice location:
  • Phone: 562-569-5808
  • Fax:
Mailing address:
  • Phone: 562-569-5808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number63042
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63042
License Number StateCA

VIII. Authorized Official

Name: SITAL MANDALIA
Title or Position: PRESIDENT
Credential: DDS
Phone: 562-569-5808