Provider Demographics
NPI:1760862031
Name:RANDHAWA, AMANDEEP KAUR
Entity type:Individual
Prefix:
First Name:AMANDEEP
Middle Name:KAUR
Last Name:RANDHAWA
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 1:5510 N MILBURN AVE APT 242
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6066
Mailing Address - Country:US
Mailing Address - Phone:559-313-8974
Mailing Address - Fax:
Practice Address - Street 1:4195 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-7025
Practice Address - Country:US
Practice Address - Phone:559-243-8961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA645141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice