Provider Demographics
NPI:1043887912
Name:JETHWANI DENTAL CORP
Entity Type:Organization
Organization Name:JETHWANI DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JETHWANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-237-2872
Mailing Address - Street 1:1732 AVIATION BLVD STE 514
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2810
Mailing Address - Country:US
Mailing Address - Phone:310-741-7953
Mailing Address - Fax:
Practice Address - Street 1:6648 IRVINE CENTER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2117
Practice Address - Country:US
Practice Address - Phone:949-237-2872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty