Provider Demographics
NPI:1437847712
Name:GANDA, MISHA (DMD)
Entity Type:Individual
Prefix:
First Name:MISHA
Middle Name:
Last Name:GANDA
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 1:510 E 3RD ST APT 301
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-1942
Mailing Address - Country:US
Mailing Address - Phone:908-294-5965
Mailing Address - Fax:
Practice Address - Street 1:510 E 3RD ST APT 301
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1942
Practice Address - Country:US
Practice Address - Phone:908-294-5965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109105122300000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program