Provider Demographics
NPI:1649572215
Name:AESTHETIC EDGE, THE DENTAL PRACTICE OF MANKIRAT GILL DDS PROF. CORP.
Entity Type:Organization
Organization Name:AESTHETIC EDGE, THE DENTAL PRACTICE OF MANKIRAT GILL DDS PROF. CORP.
Other - Org Name:AESTHETIC EDGE DENTISTRY PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:KANWAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-447-8490
Mailing Address - Street 1:3616 W SHAW AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3616 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3231
Practice Address - Country:US
Practice Address - Phone:559-271-8400
Practice Address - Fax:559-271-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58363261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA58363OtherDENTAL LICENSE OF MANKIRAT GILL DDS