=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518760057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIWAN DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2025
-----------------------------------------------------
Last Update Date | 04/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 W COURT ST STE D
-----------------------------------------------------
City | WOODLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95695-2986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-662-8115
-----------------------------------------------------
Fax | 530-662-1547
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 W COURT ST STE D
-----------------------------------------------------
City | WOODLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95695-2986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-662-8115
-----------------------------------------------------
Fax | 530-662-1547
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RITESH DIWAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 530-662-8115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------