Provider Demographics
NPI:1073885794
Name:MISTRY, PUJA (DMD)
Entity Type:Individual
Prefix:
First Name:PUJA
Middle Name:
Last Name:MISTRY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 OVERLAND AVE APT 2224
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-4502
Mailing Address - Country:US
Mailing Address - Phone:951-515-9109
Mailing Address - Fax:
Practice Address - Street 1:16111 PLUMMER ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-2036
Practice Address - Country:US
Practice Address - Phone:818-891-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist