Provider Demographics
NPI:1952889263
Name:BAJWA, JAMAL
Entity Type:Individual
Prefix:
First Name:JAMAL
Middle Name:
Last Name:BAJWA
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 1:3711 OLYMPIA DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-3460
Mailing Address - Country:US
Mailing Address - Phone:336-588-6096
Mailing Address - Fax:
Practice Address - Street 1:1301 FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2325
Practice Address - Country:US
Practice Address - Phone:919-956-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015731122300000X
NC121671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist