=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558053116
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEJDEEP RATTAN D.D.S INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2023
-----------------------------------------------------
Last Update Date | 05/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1376 CONCANNON BLVD
-----------------------------------------------------
City | LIVERMORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94550-6004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-369-7843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 919 S FULTON ST
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95391-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-369-7843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | TEJDEEP RATTAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 937-369-7843
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------