Provider Demographics
NPI:1013122241
Name:SANDHU, GAGANDEEP S
Entity Type:Individual
Prefix:DR
First Name:GAGANDEEP
Middle Name:S
Last Name:SANDHU
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 1:3749 DAWN CIRLCE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587
Mailing Address - Country:US
Mailing Address - Phone:510-395-0651
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:1160 W YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-5239
Practice Address - Country:US
Practice Address - Phone:209-624-5160
Practice Address - Fax:209-624-5168
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55620122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD55620Medicaid