Healthcare Provider Details

I. General information

NPI: 1255573705
Provider Name (Legal Business Name): PAVANDEEP KAUR KOONER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 108 8501 162ND STREET
SURREY BC
V4N1B2
CA

IV. Provider business mailing address

12776 61ST AVE
SURREY BC
V3X3M6
CA

V. Phone/Fax

Practice location:
  • Phone: 17788586232
  • Fax:
Mailing address:
  • Phone: 17788586232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number58153
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: