Provider Demographics
NPI:1285066894
Name:MANGAT GONDARA, HARSIRAT K (DMD)
Entity type:Individual
Prefix:DR
First Name:HARSIRAT
Middle Name:K
Last Name:MANGAT GONDARA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:HARSIRAT
Other - Middle Name:K
Other - Last Name:MANGAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:4218 LA COSA AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4722
Mailing Address - Country:US
Mailing Address - Phone:510-789-6417
Mailing Address - Fax:
Practice Address - Street 1:4218 LA COSA AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4722
Practice Address - Country:US
Practice Address - Phone:510-789-6417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62620122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist