Healthcare Provider Details

I. General information

NPI: 1902107527
Provider Name (Legal Business Name): G. S. ATWAL, DDS A PROF. DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14850 HIGHWAY 4 STE B
DISCOVERY BAY CA
94505-2237
US

IV. Provider business mailing address

14850 HIGHWAY 4 STE B
DISCOVERY BAY CA
94505-2237
US

V. Phone/Fax

Practice location:
  • Phone: 925-634-5353
  • Fax: 925-634-5393
Mailing address:
  • Phone: 925-634-5353
  • Fax: 925-634-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number46021
License Number StateCA

VIII. Authorized Official

Name: GURRINDER SINGH ATWAL
Title or Position: DENTIST
Credential: D.D.S.
Phone: 209-836-5393