Provider Demographics
NPI:1235684796
Name:GAJENDRAGADKAR, SURABHI (BDS, MPH, DDS)
Entity Type:Individual
Prefix:DR
First Name:SURABHI
Middle Name:
Last Name:GAJENDRAGADKAR
Suffix:
Gender:F
Credentials:BDS, MPH, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15835 WILLOW HILL DR
Mailing Address - Street 2:UNIT 3
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-3885
Mailing Address - Country:US
Mailing Address - Phone:218-730-7644
Mailing Address - Fax:
Practice Address - Street 1:3660 GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-1477
Practice Address - Country:US
Practice Address - Phone:218-730-7644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1004811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice