Provider Demographics
NPI:1831751692
Name:PANNU, TARANDEEP KAUR
Entity type:Individual
Prefix:
First Name:TARANDEEP
Middle Name:KAUR
Last Name:PANNU
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 1:2137 RED BRANGUS TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-2118
Mailing Address - Country:US
Mailing Address - Phone:206-261-0629
Mailing Address - Fax:
Practice Address - Street 1:3300 E BROAD ST STE 120
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5630
Practice Address - Country:US
Practice Address - Phone:682-518-5856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist