Provider Demographics
NPI:1770675142
Name:GODIWALA, MIRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:
Last Name:GODIWALA
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 1:19940 HOMESTEAD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-0561
Mailing Address - Country:US
Mailing Address - Phone:408-518-2808
Mailing Address - Fax:
Practice Address - Street 1:19940 HOMESTEAD RD
Practice Address - Street 2:STE100
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-0561
Practice Address - Country:US
Practice Address - Phone:408-255-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA465441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9315501Medicare ID - Type UnspecifiedDENTICAL