Provider Demographics
NPI:1659545374
Name:IMAGE DENTAL GROUP
Entity Type:Organization
Organization Name:IMAGE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASHANT
Authorized Official - Middle Name:RAMAN
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-469-4144
Mailing Address - Street 1:7557 EL CAJON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-7823
Mailing Address - Country:US
Mailing Address - Phone:619-469-4144
Mailing Address - Fax:619-469-4142
Practice Address - Street 1:7557 EL CAJON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-7823
Practice Address - Country:US
Practice Address - Phone:619-469-4144
Practice Address - Fax:619-469-4143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51847122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty