=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982597282
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIVEDITA THOTA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2025
-----------------------------------------------------
Last Update Date | 06/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2760 SE 17TH ST STE 600
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471-5561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-867-7797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16112 SUNDAY STROLL WAY
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33556-2941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-434-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN30336
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------