Provider Demographics
NPI:1124295241
Name:DALWANI, MAMTA POORAN
Entity type:Individual
Prefix:DR
First Name:MAMTA
Middle Name:POORAN
Last Name:DALWANI
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MAMTA
Other - Middle Name:POORAN
Other - Last Name:DALWANI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:12381 WILSHIRE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1063
Mailing Address - Country:US
Mailing Address - Phone:310-207-4617
Mailing Address - Fax:
Practice Address - Street 1:12381 WILSHIRE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1063
Practice Address - Country:US
Practice Address - Phone:310-207-4617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA515711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice