Provider Demographics
NPI:1346802527
Name:SANDHU, MANSIMRAN
Entity Type:Individual
Prefix:
First Name:MANSIMRAN
Middle Name:
Last Name:SANDHU
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 1:15299 WRIGLEY CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-7614
Mailing Address - Country:US
Mailing Address - Phone:408-621-4856
Mailing Address - Fax:
Practice Address - Street 1:4512 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5836
Practice Address - Country:US
Practice Address - Phone:260-238-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013233A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist