=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215608633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRALI PANDYA BDS, PHD, MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2021
-----------------------------------------------------
Last Update Date | 02/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1034 W 34TH ST #401
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90089-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-740-2012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 S HOPE ST APT 1120
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-4694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-408-7673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | SP322
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------