Healthcare Provider Details

I. General information

NPI: 1518396621
Provider Name (Legal Business Name): SHIVALI GOHEL GARG DMD, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHIVALI GOHEL DMD, MSD

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 GENESEE AVE STE 203
SAN DIEGO CA
92117
US

IV. Provider business mailing address

4320 GENESEE AVE STE 203
SAN DIEGO CA
92117-4900
US

V. Phone/Fax

Practice location:
  • Phone: 858-541-7676
  • Fax:
Mailing address:
  • Phone: 858-541-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number62958
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: