Provider Demographics
NPI:1609398098
Name:AWASTHI, NEETA
Entity Type:Individual
Prefix:
First Name:NEETA
Middle Name:
Last Name:AWASTHI
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 1:629 9TH ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1508
Mailing Address - Country:US
Mailing Address - Phone:619-424-5115
Mailing Address - Fax:
Practice Address - Street 1:629 9TH ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1508
Practice Address - Country:US
Practice Address - Phone:619-424-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1028591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program