MEDICARE: POURNAWATTIE ANDREA CHANDRADATT DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D14249	MN

General Provider Information

NPI Number	:	1972162527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	POURNAWATTIE ANDREA CHANDRADATT DDS

Provider Business Mailing Address
First Line	:	15769 WYOMING AVE
Second Line	:
City	:	SAVAGE
State	:	MN
Zip	:	55378-6627
Country	:	US
Telephone Number	:	612-803-7113
Fax Number	:

Provider Business Practice Location Address
First Line	:	7936 PORTLAND AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-1315
Country	:	US
Telephone Number	:	763-600-8613
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2019
Last Update Date	:	06/07/2019

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