=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205263191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR JANDALI DENTAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2013
-----------------------------------------------------
Last Update Date | 12/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9353 FAIRWAY VIEW PL 200
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-0961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-987-9933
-----------------------------------------------------
Fax | 909-581-6669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9353 FAIRWAY VIEW PL 200
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-0961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-987-9933
-----------------------------------------------------
Fax | 909-581-6669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | AZZA JANDALI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-987-9933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 46833
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------