Provider Demographics
NPI:1043310246
Name:VENUGOPAL, NITHYA (DMD)
Entity type:Individual
Prefix:DR
First Name:NITHYA
Middle Name:
Last Name:VENUGOPAL
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 1:7138 BRONTE PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-8590
Mailing Address - Country:US
Mailing Address - Phone:859-494-6421
Mailing Address - Fax:859-494-6421
Practice Address - Street 1:68555 RAMON RD STE D101
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3310
Practice Address - Country:US
Practice Address - Phone:951-384-6022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59930122300000X
KY82871223G0001X
TN90671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentist