Provider Demographics
NPI:1275847014
Name:MAHAJAN & KAILA PROF DENTAL CORP
Entity Type:Organization
Organization Name:MAHAJAN & KAILA PROF DENTAL CORP
Other - Org Name:TUSTIN SMILE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANIL
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:MAHAJAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-665-0005
Mailing Address - Street 1:12791 NEWPORT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-8023
Mailing Address - Country:US
Mailing Address - Phone:714-665-0005
Mailing Address - Fax:714-665-0055
Practice Address - Street 1:12791 NEWPORT AVE STE 200
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-8023
Practice Address - Country:US
Practice Address - Phone:714-665-0005
Practice Address - Fax:714-665-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58280122300000X
CA57847122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty