Healthcare Provider Details

I. General information

NPI: 1780074468
Provider Name (Legal Business Name): MILAN JINJUWADIA B.D.S.,M.P.H.,D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2313 N CORRAL HOLLOW RD
TRACY CA
95376-9401
US

IV. Provider business mailing address

4445 VALLEY AVE APT L
PLEASANTON CA
94566-6159
US

V. Phone/Fax

Practice location:
  • Phone: 209-371-0710
  • Fax:
Mailing address:
  • Phone: 205-919-9192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number64329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: