Provider Demographics
NPI:1356782486
Name:PANIGRAHI, SANJUKTA
Entity type:Individual
Prefix:
First Name:SANJUKTA
Middle Name:
Last Name:PANIGRAHI
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 1:11660 CHURCH ST APT 42
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8920
Mailing Address - Country:US
Mailing Address - Phone:619-206-4556
Mailing Address - Fax:
Practice Address - Street 1:15290 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8515
Practice Address - Country:US
Practice Address - Phone:619-206-4556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29319122300000X
CA65328122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist