Provider Demographics
NPI:1326427840
Name:SIDHU, KOMAL
Entity Type:Individual
Prefix:
First Name:KOMAL
Middle Name:
Last Name:SIDHU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4435 1ST ST # 105
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-4915
Mailing Address - Country:US
Mailing Address - Phone:917-854-0088
Mailing Address - Fax:
Practice Address - Street 1:1915 4TH ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550
Practice Address - Country:US
Practice Address - Phone:917-854-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0404731223G0001X
CADDS1006391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice