Provider Demographics
NPI:1861049736
Name:THYAGARAJ, GLADVIN MURPHY (DDS)
Entity type:Individual
Prefix:
First Name:GLADVIN
Middle Name:MURPHY
Last Name:THYAGARAJ
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 1:22780 VISTA GRANDE WAY
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-4943
Mailing Address - Country:US
Mailing Address - Phone:909-462-0125
Mailing Address - Fax:
Practice Address - Street 1:3780 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1080
Practice Address - Country:US
Practice Address - Phone:619-265-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-24
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1038411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice