Healthcare Provider Details

I. General information

NPI: 1346403169
Provider Name (Legal Business Name): MIRAJ KISHOR SANGHVI DDS,MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 PORTER AVE SUITE 400
STOCKTON CA
95207-4232
US

IV. Provider business mailing address

756 PORTER AVE SUITE 400
STOCKTON CA
95207-4232
US

V. Phone/Fax

Practice location:
  • Phone: 209-951-6387
  • Fax:
Mailing address:
  • Phone: 209-951-6387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number53943
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA115872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: