Provider Demographics
NPI:1336520980
Name:MOHAN, SUGANDHA
Entity type:Individual
Prefix:
First Name:SUGANDHA
Middle Name:
Last Name:MOHAN
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 1:4950 E VAN BUREN ST APT 328
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-7050
Mailing Address - Country:US
Mailing Address - Phone:646-264-8736
Mailing Address - Fax:
Practice Address - Street 1:1820 N 75TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85035-4533
Practice Address - Country:US
Practice Address - Phone:623-255-3607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZD009307122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program