Provider Demographics
NPI:1558787457
Name:AMIN, MITUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITUL
Middle Name:
Last Name:AMIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5861 SILVEIRA ST
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-4627
Mailing Address - Country:US
Mailing Address - Phone:909-859-5359
Mailing Address - Fax:
Practice Address - Street 1:8415 HAVEN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3893
Practice Address - Country:US
Practice Address - Phone:909-980-2272
Practice Address - Fax:909-980-6233
Is Sole Proprietor?:No
Enumeration Date:2014-03-16
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA633421223G0001X
AZD0110551223G0001X
TX297401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7558630001Medicare NSC