Provider Demographics
NPI:1679970537
Name:PANNU, DALVIR
Entity type:Individual
Prefix:
First Name:DALVIR
Middle Name:
Last Name:PANNU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40880 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4334
Mailing Address - Country:US
Mailing Address - Phone:510-792-9292
Mailing Address - Fax:510-792-9296
Practice Address - Street 1:40880 FREMONT BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-4334
Practice Address - Country:US
Practice Address - Phone:510-792-9292
Practice Address - Fax:510-792-9296
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist