=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275003048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AJAY D. AMIN D.D.S. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2018
-----------------------------------------------------
Last Update Date | 01/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3625 MIDWAY DR STE A
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92110-5253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-224-2204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11760 CARMEL CREEK RD APT 305
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-6612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-756-9019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | AJAY DILIP AMIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 619-224-2204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------