=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285301390
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GANGLANI DMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2021
-----------------------------------------------------
Last Update Date | 08/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 MAIN ST STE 103
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28075-7491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-516-0275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3935 SOMERDALE LN STE 110
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28205-4515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-516-0275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF IMPLEMENTATION
-----------------------------------------------------
Name | RICHARD B VELAZQUE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-516-0275
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------