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General NPI Number Information
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NPI Number | 1457849960
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Entity Type | Organization
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Legal Business Name | DENTAL WHITE MANAGEMENT LLC
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Dates
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Enumeration Date | 04/30/2018
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Last Update Date | 04/30/2018
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Provider Practice Location Address
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Address Line | 43625 MISSION BLVD STE 105
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City | FREMONT
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State | CA
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Zip | 94539-5800
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Country | US
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Telephone | 669-245-7494
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Fax |
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Provider Business Mailing Address
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Address Line | 3680 BEACON AVE APT 320
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City | FREMONT
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State | CA
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Zip | 94538-3046
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Country | US
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Telephone | 224-877-0645
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Fax | 669-265-0400
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Authorized Official
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Title or Position | PERIODONTIST
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Name | DR. LOGESH SWAYAMPRAKASAM
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Credential | BDS,MPH, MS
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Telephone | 224-877-0645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DDS100140
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License Number State | CA
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