=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295990786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RASWINDER KAUR NAGRA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2008
-----------------------------------------------------
Last Update Date | 03/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10811 ASHTON AVE APT 209
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-4886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-254-5241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1233 HOWARD ST APT 3G
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94103-2774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 403-568-7666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 58158
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------