Provider Demographics
NPI:1801204508
Name:TANEJA, NIDHI (DDS)
Entity Type:Individual
Prefix:
First Name:NIDHI
Middle Name:
Last Name:TANEJA
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 1:3401 OAKDALE RD # 505
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355
Mailing Address - Country:US
Mailing Address - Phone:209-287-5940
Mailing Address - Fax:
Practice Address - Street 1:5757 PACIFIC AVE STE A-145
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5100
Practice Address - Country:US
Practice Address - Phone:310-694-4419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059687122300000X
CT121631223P0221X
390200000X
CA1043391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program