MEDICARE: VIJAYA KV PRABHU.DDS. A PROFFESSIONAL CORP

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	38736	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1223G0001X	OTHER	CA	DENTIST-GENERAL PRACITICE

General Provider Information

NPI Number	:	1316161961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIJAYA KV PRABHU.DDS. A PROFFESSIONAL CORP

Provider Business Mailing Address
First Line	:	13350 CAMINO DEL SUR
Second Line	:	SUITE # 6
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-4473
Country	:	US
Telephone Number	:	858-484-9977
Fax Number	:	858-484-9979

Provider Business Practice Location Address
First Line	:	13350 CAMINO DEL SUR
Second Line	:	SUITE # 6
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-4473
Country	:	US
Telephone Number	:	858-484-9977
Fax Number	:	858-484-9979

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PRABHU KV PRABHU
Credential	:	DDS
Telephone Number	:	858-484-9977

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	08/22/2020

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