Provider Demographics
NPI:1871992065
Name:GOPAL, MALA (DR)
Entity type:Individual
Prefix:
First Name:MALA
Middle Name:
Last Name:GOPAL
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44197 GLENDORA DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-5939
Mailing Address - Country:US
Mailing Address - Phone:925-219-6119
Mailing Address - Fax:
Practice Address - Street 1:1333 MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5212
Practice Address - Country:US
Practice Address - Phone:408-445-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist