=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215519798
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHRUTI TANDON D.M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2021
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 CRESTVIEW DR
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95050-6503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-272-3480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34641 WINSLOW TER
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94555-3643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHRUTI TANDON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 919-272-3480
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------