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General NPI Number Information
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NPI Number | 1972162527
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Entity Type | Individual
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Provider Name | POURNAWATTIE ANDREA CHANDRADATT DDS
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Gender | Female
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Dates
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Enumeration Date | 06/07/2019
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Last Update Date | 06/07/2019
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Provider Practice Location Address
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Address Line | 7936 PORTLAND AVE S
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City | BLOOMINGTON
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State | MN
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Zip | 55420-1315
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Country | US
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Telephone | 763-600-8613
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Fax |
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Provider Business Mailing Address
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Address Line | 15769 WYOMING AVE
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City | SAVAGE
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State | MN
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Zip | 55378-6627
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Country | US
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Telephone | 612-803-7113
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D14249
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License Number State | MN
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