Provider Demographics
NPI:1346403169
Name:SANGHVI, MIRAJ KISHOR (DDS,MD)
Entity Type:Individual
Prefix:
First Name:MIRAJ
Middle Name:KISHOR
Last Name:SANGHVI
Suffix:
Gender:M
Credentials:DDS,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 PORTER AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4232
Mailing Address - Country:US
Mailing Address - Phone:209-951-6387
Mailing Address - Fax:
Practice Address - Street 1:756 PORTER AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4232
Practice Address - Country:US
Practice Address - Phone:209-951-6387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA539431223S0112X
CAA115872204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery