=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689366247
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | POOJA PATEL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2023
-----------------------------------------------------
Last Update Date | 06/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11561 FOOTHILL BLVD STE 104
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-3999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-656-0473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3184 E LAVENDER DR,
-----------------------------------------------------
City | CHINO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-656-0473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DDS110279
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------