Provider Demographics
NPI:1972025518
Name:KRISHNAMOORTHY, VIJETA (DMD)
Entity type:Individual
Prefix:DR
First Name:VIJETA
Middle Name:
Last Name:KRISHNAMOORTHY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 PARKVIEW CT
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-8200
Mailing Address - Country:US
Mailing Address - Phone:559-287-0420
Mailing Address - Fax:
Practice Address - Street 1:23111 VENTURA BLVD STE 204
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1160
Practice Address - Country:US
Practice Address - Phone:818-225-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS101280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADDS101280Medicaid