Provider Demographics
NPI:1821403312
Name:GILL, SANGRAM
Entity Type:Individual
Prefix:
First Name:SANGRAM
Middle Name:
Last Name:GILL
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 1:2725 WAGON TRAIN LN
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3649
Mailing Address - Country:US
Mailing Address - Phone:909-272-8131
Mailing Address - Fax:
Practice Address - Street 1:2725 WAGON TRAIN LN
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3649
Practice Address - Country:US
Practice Address - Phone:909-272-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63492122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist