Basic Information
Provider Information | |||||||||
NPI: | 1922643899 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GILL | ||||||||
FirstName: | SIMRAN | ||||||||
MiddleName: | SINGH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2400 POLE LINE RD APT 35 | ||||||||
Address2: |   | ||||||||
City: | DAVIS | ||||||||
State: | CA | ||||||||
PostalCode: | 956180525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2154334778 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 110 NUT TREE PKWY | ||||||||
Address2: |   | ||||||||
City: | VACAVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956873251 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074518390 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2019 | ||||||||
LastUpdateDate: | 11/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 104535 | CA | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 104535 | 01 | CA | DENTAL LICENSE NUMBER | OTHER |