MEDICARE: GURJIT S RANDHWA DDS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1306594312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GURJIT S RANDHWA DDS, INC.

Provider Business Mailing Address
First Line	:	2229 SANTA CLARA AVE STE E
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94501-4409
Country	:	US
Telephone Number	:	510-521-3300
Fax Number	:	510-521-3301

Provider Business Practice Location Address
First Line	:	2229 SANTA CLARA AVE STE E
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94501-4409
Country	:	US
Telephone Number	:	510-521-3300
Fax Number	:	510-521-3301

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GURJIT RANDHAWA
Credential	:	DDS,DMD
Telephone Number	:	510-220-0415

Provider Enumeration Date	:	03/17/2022
Last Update Date	:	06/23/2022

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