MEDICARE: DIVYA AMBARISH PATHAK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	32930	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B32930	OTHER	CA	DENTI-CAL PROVIDER NUMBER

General Provider Information

NPI Number	:	1134297963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVYA AMBARISH PATHAK DDS

Provider Business Mailing Address
First Line	:	19319 BECHARD AVE
Second Line	:
City	:	CERRITOS
State	:	CA
Zip	:	90703-7208
Country	:	US
Telephone Number	:	562-402-9437
Fax Number	:

Provider Business Practice Location Address
First Line	:	3756 SANTA ROSALIA DR
Second Line	:	SUITE 227
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-3616
Country	:	US
Telephone Number	:	323-292-7124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/08/2007

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