Provider Demographics
NPI:1497379325
Name:MEHTA, POOJA (DMD)
Entity Type:Individual
Prefix:
First Name:POOJA
Middle Name:
Last Name:MEHTA
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 1:2308 WINDSONG LN
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-7912
Mailing Address - Country:US
Mailing Address - Phone:254-493-0898
Mailing Address - Fax:
Practice Address - Street 1:1315 SHAW AVE STE 102
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3963
Practice Address - Country:US
Practice Address - Phone:315-350-8795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-06
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CANA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program