Provider Demographics
NPI:1003675695
Name:RANDHAWA, RAJDEEP K (DDS)
Entity Type:Individual
Prefix:
First Name:RAJDEEP
Middle Name:K
Last Name:RANDHAWA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11975 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5171
Mailing Address - Country:US
Mailing Address - Phone:909-913-2870
Mailing Address - Fax:
Practice Address - Street 1:11975 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5171
Practice Address - Country:US
Practice Address - Phone:909-913-2870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1099461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice