=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073169850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARSIRAT GONDARA, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2019
-----------------------------------------------------
Last Update Date | 08/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 795 COCHRANE RD STE 120
-----------------------------------------------------
City | MORGAN HILL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95037-2874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-789-6417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2327 BENTLEY RIDGE DR
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95138-2424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-688-4923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. HARSIRAT GONDARA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-789-6417
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------