=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912167479
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BHARATHI GORTHI DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2008
-----------------------------------------------------
Last Update Date | 11/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 665 S KNICKERBOCKER DR 9
-----------------------------------------------------
City | SUNNYVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94087-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-634-3368
-----------------------------------------------------
Fax | 815-346-8791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 DAYTON AVE
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95051-6410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-246-4648
-----------------------------------------------------
Fax | 815-346-8791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 57002
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------