Provider Demographics
NPI:1518310408
Name:KHATRI, SUVIDHA
Entity Type:Individual
Prefix:
First Name:SUVIDHA
Middle Name:
Last Name:KHATRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 SHORELINE DR APT 204
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6053
Mailing Address - Country:US
Mailing Address - Phone:770-882-8958
Mailing Address - Fax:
Practice Address - Street 1:530 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4525
Practice Address - Country:US
Practice Address - Phone:800-579-3783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100440122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist