Healthcare Provider Details

I. General information

NPI: 1659881100
Provider Name (Legal Business Name): AMANDEEP BHULLAR DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 WILLOW ST STE 7
SAN JOSE CA
95125-5101
US

IV. Provider business mailing address

1660 WILLOW ST STE 7
SAN JOSE CA
95125-5101
US

V. Phone/Fax

Practice location:
  • Phone: 408-677-6811
  • Fax:
Mailing address:
  • Phone: 408-677-6811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number55373
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number55373
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: