Provider Demographics
NPI:1104964790
Name:DOGRA, GAUTAM K (DDS)
Entity type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:K
Last Name:DOGRA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 GABRIEL CT
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4778
Mailing Address - Country:US
Mailing Address - Phone:530-680-7932
Mailing Address - Fax:916-736-2071
Practice Address - Street 1:2801 O ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6410
Practice Address - Country:US
Practice Address - Phone:916-736-2801
Practice Address - Fax:916-736-2071
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48450122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD48450Medicaid