Provider Demographics
NPI:1316161961
Name:VIJAYA KV PRABHU.DDS. A PROFFESSIONAL CORP
Entity type:Organization
Organization Name:VIJAYA KV PRABHU.DDS. A PROFFESSIONAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRABHU
Authorized Official - Middle Name:KV
Authorized Official - Last Name:PRABHU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-484-9977
Mailing Address - Street 1:13350 CAMINO DEL SUR
Mailing Address - Street 2:SUITE # 6
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-4473
Mailing Address - Country:US
Mailing Address - Phone:858-484-9977
Mailing Address - Fax:858-484-9979
Practice Address - Street 1:13350 CAMINO DEL SUR
Practice Address - Street 2:SUITE # 6
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-4473
Practice Address - Country:US
Practice Address - Phone:858-484-9977
Practice Address - Fax:858-484-9979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA387361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1223G0001XOtherDENTIST-GENERAL PRACITICE