Provider Demographics
NPI:1174975882
Name:MOBILE DENTISTRY OF CA INC
Entity type:Organization
Organization Name:MOBILE DENTISTRY OF CA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:949-529-1095
Mailing Address - Street 1:4 BRAGG
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13522 NEWPORT AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3707
Practice Address - Country:US
Practice Address - Phone:949-529-1095
Practice Address - Fax:949-417-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61024332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment