Provider Demographics
NPI:1861512428
Name:BANDALA, JOSE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:L
Last Name:BANDALA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 LEAD HILL BLVD
Mailing Address - Street 2:STE #300
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2853
Mailing Address - Country:US
Mailing Address - Phone:916-782-0440
Mailing Address - Fax:916-783-6332
Practice Address - Street 1:1620 LEAD HILL BLVD # 300
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3033
Practice Address - Country:US
Practice Address - Phone:916-782-0440
Practice Address - Fax:916-783-6332
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA412331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice