=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184271934
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VARUN MITTAL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2019
-----------------------------------------------------
Last Update Date | 07/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 FERRARI RANCH RD
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95648-7414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-432-5501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | WESTERN DENTAL 1701 WATT AVE
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | DDS104206
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------