Healthcare Provider Details

I. General information

NPI: 1528433935
Provider Name (Legal Business Name): JATT DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 INDIAN TRAIL RD SUITE#300
NORCROSS GA
30093-5524
US

IV. Provider business mailing address

1235 INDIAN TRAIL RD SUITE#300
NORCROSS GA
30093-5524
US

V. Phone/Fax

Practice location:
  • Phone: 770-837-9431
  • Fax:
Mailing address:
  • Phone: 770-837-9431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN012628
License Number StateGA

VIII. Authorized Official

Name: DR. RANDEEP S BHULLAR
Title or Position: PRESIDENT
Credential: DDS
Phone: 770-837-9431