Provider Demographics
NPI:1912510645
Name:PANNU, MANDEEP KAUR
Entity Type:Individual
Prefix:
First Name:MANDEEP
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 1:4379 LEGACY GREENS DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-7109
Mailing Address - Country:US
Mailing Address - Phone:203-703-2762
Mailing Address - Fax:
Practice Address - Street 1:9608 KENWOOD RD
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6129
Practice Address - Country:US
Practice Address - Phone:513-791-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.027057122300000X
MI2901600575122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist