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General NPI Number Information
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NPI Number | 1417641473
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Entity Type | Individual
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Provider Name | JAI-INDER GHOTRA DMD
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Gender | Male
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Dates
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Enumeration Date | 06/05/2023
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Last Update Date | 08/02/2024
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Provider Practice Location Address
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Address Line | 4500 8TH DIVISION RD
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City | COLUMBIA
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State | SC
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Zip | 29207-5700
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Country | US
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Telephone | 803-751-2618
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 SHADOW LN
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City | LAS VEGAS
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State | NV
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Zip | 89106-4124
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 14037860-9926
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License Number State | UT
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