=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598396681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIVYA RANI SEELI DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2020
-----------------------------------------------------
Last Update Date | 01/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3945 MARYSVILLE BLVD
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95838-3762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-646-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2679 RIVER PLAZA DR APT 302
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95833-3284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-917-6426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 104781
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------