Provider Demographics
NPI:1285291351
Name:JAGANATHAN, MOHAN RAJ (DDS)
Entity type:Individual
Prefix:DR
First Name:MOHAN RAJ
Middle Name:
Last Name:JAGANATHAN
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 1:2402 N BEN WILSON ST APT 5209
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-5081
Mailing Address - Country:US
Mailing Address - Phone:516-813-7971
Mailing Address - Fax:
Practice Address - Street 1:4109 HOUSTON HWY STE 200
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5092
Practice Address - Country:US
Practice Address - Phone:516-813-7971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35004122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist