MEDICARE: TULSI MALI DMD

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	13601	CT
2	122300000X	Dentist	108626	CA

General Provider Information

NPI Number	:	1417522491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TULSI MALI DMD

Provider Business Mailing Address
First Line	:	5620 LAKE MURRAY BLVD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-1981
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5620 LAKE MURRAY BLVD
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-1981
Country	:	US
Telephone Number	:	619-324-4195
Fax Number	:

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

Provider Enumeration Date	:	05/23/2021
Last Update Date	:	04/26/2023

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