Provider Demographics
NPI:1932516804
Name:JOSE, SANJU P (DDS, MDS)
Entity Type:Individual
Prefix:DR
First Name:SANJU
Middle Name:P
Last Name:JOSE
Suffix:
Gender:M
Credentials:DDS, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PINE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:PA
Mailing Address - Zip Code:15126-9332
Mailing Address - Country:US
Mailing Address - Phone:410-913-4760
Mailing Address - Fax:
Practice Address - Street 1:6395 DOBBIN RD STE 208
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4759
Practice Address - Country:US
Practice Address - Phone:410-997-1189
Practice Address - Fax:410-992-5474
Is Sole Proprietor?:No
Enumeration Date:2014-07-12
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD163081223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics