Provider Demographics
NPI:1285044735
Name:RANDHAWA, JASKAREN (DMD)
Entity Type:Individual
Prefix:
First Name:JASKAREN
Middle Name:
Last Name:RANDHAWA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 BROADWAY
Mailing Address - Street 2:#502
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-5601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 BROADWAY
Practice Address - Street 2:#502
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-5601
Practice Address - Country:US
Practice Address - Phone:212-575-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2017-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0582191122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04289305Medicaid