=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457073850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAMAL SANDHU DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2022
-----------------------------------------------------
Last Update Date | 09/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1170 W 11TH ST
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95376-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-839-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 741 N PERGOLA CT
-----------------------------------------------------
City | MOUNTAIN HOUSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95391-1306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-307-5948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KAMAL PREET KAUR SANDHU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-307-5948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------