Provider Demographics
NPI:1760506141
Name:KUNTAL S PANDIT DMD PC
Entity Type:Organization
Organization Name:KUNTAL S PANDIT DMD PC
Other - Org Name:ONEONTA DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BLACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-625-4384
Mailing Address - Street 1:28425 STATE HIGHWAY 75
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-1657
Mailing Address - Country:US
Mailing Address - Phone:205-625-4384
Mailing Address - Fax:205-625-4737
Practice Address - Street 1:28425 STATE HIGHWAY 75
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-1657
Practice Address - Country:US
Practice Address - Phone:205-625-4384
Practice Address - Fax:205-625-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51077759OtherBLUE CROSS PROVIDER #
AL529916600Medicaid
353978OtherCOMPBEN ID
577227OtherUNITED CONCORDIA PROVIDER