Provider Demographics
NPI:1346732153
Name:VIRK, AMRITTEJ SINGH
Entity Type:Individual
Prefix:
First Name:AMRITTEJ
Middle Name:SINGH
Last Name:VIRK
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 1:630 N KIMBALL AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6887
Mailing Address - Country:US
Mailing Address - Phone:817-251-9985
Mailing Address - Fax:
Practice Address - Street 1:630 N KIMBALL AVE STE 110
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-251-9985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34421122300000X, 1223X2210X
AZ9990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No122300000XDental ProvidersDentist