Provider Demographics
NPI:1134297963
Name:PATHAK, DIVYA AMBARISH (DDS)
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:AMBARISH
Last Name:PATHAK
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 1:19319 BECHARD AVE
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-7208
Mailing Address - Country:US
Mailing Address - Phone:562-402-9437
Mailing Address - Fax:
Practice Address - Street 1:3756 SANTA ROSALIA DR
Practice Address - Street 2:SUITE 227
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3616
Practice Address - Country:US
Practice Address - Phone:323-292-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA329301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB32930OtherDENTI-CAL PROVIDER NUMBER