Provider Demographics
NPI:1881032944
Name:PATHAK-PAUDEL, ICHHYA (DMD)
Entity type:Individual
Prefix:
First Name:ICHHYA
Middle Name:
Last Name:PATHAK-PAUDEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 JULIANN WAY
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-7549
Mailing Address - Country:US
Mailing Address - Phone:203-512-5412
Mailing Address - Fax:
Practice Address - Street 1:1210, 106 EAST PARK ST
Practice Address - Street 2:STE 106
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023
Practice Address - Country:US
Practice Address - Phone:831-902-2829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18564251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program