Healthcare Provider Details

I. General information

NPI: 1902963051
Provider Name (Legal Business Name): GAGANDEEP SINGH KOHLI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16177 HESPERIAN BLVD
SAN LORENZO CA
94580-2451
US

IV. Provider business mailing address

16177 HESPERIAN BLVD
SAN LORENZO CA
94580-2451
US

V. Phone/Fax

Practice location:
  • Phone: 510-276-6930
  • Fax: 510-276-1061
Mailing address:
  • Phone: 510-276-6930
  • Fax: 510-276-1061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number49124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: