Healthcare Provider Details

I. General information

NPI: 1407235385
Provider Name (Legal Business Name): TANVI DODIA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2015
Last Update Date: 05/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 MANILA AVE FL 1
JERSEY CITY NJ
07302-2539
US

IV. Provider business mailing address

425 MANILA AVE FL 1
JERSEY CITY NJ
07302-2539
US

V. Phone/Fax

Practice location:
  • Phone: 312-813-8448
  • Fax:
Mailing address:
  • Phone: 312-813-8448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00111200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number005493
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: