Provider Demographics
NPI:1770631087
Name:MUNDRA, HARJEET
Entity Type:Individual
Prefix:
First Name:HARJEET
Middle Name:
Last Name:MUNDRA
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 1:16 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3911
Mailing Address - Country:US
Mailing Address - Phone:508-425-7180
Mailing Address - Fax:508-459-8757
Practice Address - Street 1:16 PARK AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3911
Practice Address - Country:US
Practice Address - Phone:508-425-7180
Practice Address - Fax:508-459-8757
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0204285Medicaid
MA110084296AMedicaid
MA1770631087Medicaid
MA1811224686Medicaid