1649572215 NPI number — AESTHETIC EDGE, THE DENTAL PRACTICE OF MANKIRAT GILL DDS PROF. CORP.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649572215 NPI number — AESTHETIC EDGE, THE DENTAL PRACTICE OF MANKIRAT GILL DDS PROF. CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AESTHETIC EDGE, THE DENTAL PRACTICE OF MANKIRAT GILL DDS PROF. CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AESTHETIC EDGE DENTISTRY PC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649572215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3616 W SHAW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93711-3231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3616 W SHAW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93711-3231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-271-8400
Provider Business Practice Location Address Fax Number:
559-271-8401
Provider Enumeration Date:
12/02/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GILL
Authorized Official First Name:
KANWAR
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
559-447-8490

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  58363 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 58363 . This is a "DENTAL LICENSE OF MANKIRAT GILL DDS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".