Provider Demographics
NPI:1073898144
Name:NIDGUNDI, NIMISHA (DDS)
Entity Type:Individual
Prefix:
First Name:NIMISHA
Middle Name:
Last Name:NIDGUNDI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3575 LEHIGH DR APT 24
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-6075
Mailing Address - Country:US
Mailing Address - Phone:408-234-0162
Mailing Address - Fax:
Practice Address - Street 1:3030 ALUM ROCK AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-2807
Practice Address - Country:US
Practice Address - Phone:408-234-0162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA58682OtherPPO