Healthcare Provider Details

I. General information

NPI: 1942936372
Provider Name (Legal Business Name): ANDEEP SANGHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3246 W GRANT LINE RD
TRACY CA
95304-8427
US

IV. Provider business mailing address

2473 DETERT ST
LIVERMORE CA
94550-2515
US

V. Phone/Fax

Practice location:
  • Phone: 209-213-7808
  • Fax:
Mailing address:
  • Phone: 317-997-1769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12013845A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number109422
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12013845A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number109422
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: