Healthcare Provider Details

I. General information

NPI: 1598823031
Provider Name (Legal Business Name): MODERN DENTAL PROFESSIONALS - SANDHU, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 WILMINGTON PIKE
CENTERVILLE OH
45459-7006
US

IV. Provider business mailing address

8415 DATAPOINT DR SUITE 1020
SAN ANTONIO TX
78229-3298
US

V. Phone/Fax

Practice location:
  • Phone: 937-848-3024
  • Fax:
Mailing address:
  • Phone: 714-578-6358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.023513
License Number StateOH

VIII. Authorized Official

Name: NAVDEEP SANDHU
Title or Position: PRESIDENT
Credential: DDS
Phone: 714-578-6358