=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275241028
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIMALA VONTELA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2022
-----------------------------------------------------
Last Update Date | 11/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 527 E CENTER ST
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95336-4719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-823-7655
-----------------------------------------------------
Fax | 209-823-7656
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 527 E CENTER ST
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95336-4719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-823-7655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VIMALA VONTELA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 209-823-7655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------