=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982689998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMRIT P KULLAR D.M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2005
-----------------------------------------------------
Last Update Date | 08/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4598 S TRACY BLVD SUITE 150
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95377-8107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-597-0381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 S PACIFICO ST
-----------------------------------------------------
City | MOUNTAIN HOUSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95391-2072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-597-0381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 54356
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------