=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023228087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | POORNIMA DUTTA D.D.S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8201 EDGEWATER DR
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94621-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-568-3577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4011 HEMINGWAY CMN
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94536-6019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-797-4155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 55076
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------