1174655070 NPI number — SAILAJA S DONTHINENI DDS INC

Table of content: MADISON MOORE MS, LCGC (NPI 1760360028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174655070 NPI number — SAILAJA S DONTHINENI DDS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAILAJA S DONTHINENI DDS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174655070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3466 MT DIABLO BLVD
Provider Second Line Business Mailing Address:
C207
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-299-1504
Provider Business Mailing Address Fax Number:
925-299-1514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3466 MT DIABLO BLVD
Provider Second Line Business Practice Location Address:
C207
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-299-1504
Provider Business Practice Location Address Fax Number:
925-299-1514
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DONTHINENI
Authorized Official First Name:
SURESH
Authorized Official Middle Name:
Authorized Official Title or Position:
CHEIF FINANCIAL OFFICER
Authorized Official Telephone Number:
415-290-8560

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  46584 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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