Provider Demographics
NPI:1972162527
Name:CHANDRADATT, POURNAWATTIE ANDREA (DDS)
Entity Type:Individual
Prefix:
First Name:POURNAWATTIE
Middle Name:ANDREA
Last Name:CHANDRADATT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15769 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-6627
Mailing Address - Country:US
Mailing Address - Phone:612-803-7113
Mailing Address - Fax:
Practice Address - Street 1:7936 PORTLAND AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1315
Practice Address - Country:US
Practice Address - Phone:763-600-8613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND142491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice