Healthcare Provider Details

I. General information

NPI: 1487683702
Provider Name (Legal Business Name): CHETAN KUMAR MEHTA D.M.D., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13372 NEWPORT AVE SUITE C
TUSTIN CA
92780-3426
US

IV. Provider business mailing address

5 VILLAGER
IRVINE CA
92602-2459
US

V. Phone/Fax

Practice location:
  • Phone: 714-838-1238
  • Fax: 714-838-9586
Mailing address:
  • Phone: 714-389-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD49597
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: