Provider Demographics
NPI:1275040909
Name:BANSI, HARJOT S
Entity Type:Individual
Prefix:
First Name:HARJOT
Middle Name:S
Last Name:BANSI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2941 W LOWELL AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-7312
Mailing Address - Country:US
Mailing Address - Phone:209-855-0541
Mailing Address - Fax:
Practice Address - Street 1:530 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4525
Practice Address - Country:US
Practice Address - Phone:477-302-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102231122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist