Provider Demographics
NPI:1063506053
Name:GANESH, ROSHEN (DDS)
Entity Type:Individual
Prefix:
First Name:ROSHEN
Middle Name:
Last Name:GANESH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 7TH ST
Mailing Address - Street 2:#101
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2693
Mailing Address - Country:US
Mailing Address - Phone:310-458-4000
Mailing Address - Fax:310-458-4003
Practice Address - Street 1:1418 7TH ST
Practice Address - Street 2:#101
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2693
Practice Address - Country:US
Practice Address - Phone:310-458-4000
Practice Address - Fax:310-458-4003
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA497521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice