Provider Demographics
NPI:1427898345
Name:BANSAL, SHIPRA
Entity type:Individual
Prefix:
First Name:SHIPRA
Middle Name:
Last Name:BANSAL
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 1:501 WALES DR
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 PROGRESS CIR STE C
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6262
Practice Address - Country:US
Practice Address - Phone:678-365-0322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN123561122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program