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General NPI Number Information
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NPI Number | 1407367824
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Entity Type | Organization
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Legal Business Name | DR. JOTSNA'S DENTAL OFFICE
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Dates
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Enumeration Date | 10/12/2017
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Last Update Date | 10/12/2017
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Provider Practice Location Address
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Address Line | 3848 MCHENRY AVE STE 130
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City | MODESTO
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State | CA
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Zip | 95356-1599
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Country | US
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Telephone | 209-523-2100
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Fax | 209-523-2101
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Provider Business Mailing Address
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Address Line | 3848 MCHENRY AVE STE 130
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City | MODESTO
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State | CA
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Zip | 95356-1599
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Country | US
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Telephone | 209-523-2100
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Fax | 209-523-2101
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Authorized Official
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Title or Position | OWNER/DDS
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Name | DR. JOTSNA GANGADHARAN
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Credential | DDS
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Telephone | 209-523-2100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 53790
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License Number State | CA
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