Healthcare Provider Details

I. General information

NPI: 1265037444
Provider Name (Legal Business Name): SANDHU PHAGURA DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 S MAIN ST
MILPITAS CA
95035-5319
US

IV. Provider business mailing address

412 S MAIN ST
MILPITAS CA
95035-5319
US

V. Phone/Fax

Practice location:
  • Phone: 408-809-9500
  • Fax:
Mailing address:
  • Phone: 408-809-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROOP PHAGURA
Title or Position: SECRETARY
Credential:
Phone: 510-323-3704