MEDICARE: MANSIMRAN SANDHU

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	122300000X	Dentist	12013233A	IN

General Provider Information

NPI Number	:	1346802527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANSIMRAN SANDHU

Provider Business Mailing Address
First Line	:	15299 WRIGLEY CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-7614
Country	:	US
Telephone Number	:	408-621-4856
Fax Number	:

Provider Business Practice Location Address
First Line	:	4512 PARNELL AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-5836
Country	:	US
Telephone Number	:	260-238-8899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2019
Last Update Date	:	07/08/2019

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Directions to “ MANSIMRAN SANDHU ” Practice Location

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