MEDICARE: EVERGREEN SMILES 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1699540682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN SMILES INC

Provider Business Mailing Address
First Line	:	4379 LEGACY GREENS DR
Second Line	:
City	:	BATAVIA
State	:	OH
Zip	:	45103-7109
Country	:	US
Telephone Number	:	203-703-2762
Fax Number	:

Provider Business Practice Location Address
First Line	:	9100 W CHESTER TOWNE CTR STE 9270
Second Line	:
City	:	WEST CHESTER
State	:	OH
Zip	:	45069-3106
Country	:	US
Telephone Number	:	203-703-2762
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. MANDEEP KAUR PANNU
Credential	:	DMD
Telephone Number	:	203-703-2762

Provider Enumeration Date	:	11/20/2023
Last Update Date	:	11/20/2023

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Directions to “EVERGREEN SMILES INC ” Practice Location

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