Healthcare Provider Details

I. General information

NPI: 1639914096
Provider Name (Legal Business Name): AKSHAYA RAVIRAJ DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 S TRACY BLVD STE 170
TRACY CA
95376-9111
US

IV. Provider business mailing address

2600 S TRACY BLVD STE 170
TRACY CA
95376-9111
US

V. Phone/Fax

Practice location:
  • Phone: 209-836-5441
  • Fax:
Mailing address:
  • Phone: 209-836-5441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS113645
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: