Provider Demographics
NPI:1598942500
Name:JAISWAL, EKTA
Entity Type:Individual
Prefix:
First Name:EKTA
Middle Name:
Last Name:JAISWAL
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 1:11850 CYPRESS CANYON RD
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-5715
Mailing Address - Country:US
Mailing Address - Phone:619-251-4234
Mailing Address - Fax:
Practice Address - Street 1:1101 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2706
Practice Address - Country:US
Practice Address - Phone:714-480-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56722122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist