Provider Demographics
NPI:1760906861
Name:PANCHOLI, MEGHANA (DDS)
Entity Type:Individual
Prefix:
First Name:MEGHANA
Middle Name:
Last Name:PANCHOLI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3453 BAYWOOD TER APT 201
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-7419
Mailing Address - Country:US
Mailing Address - Phone:408-797-6468
Mailing Address - Fax:
Practice Address - Street 1:678 N WILSON WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4272
Practice Address - Country:US
Practice Address - Phone:209-235-0226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101584122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist