Provider Demographics
NPI:1366051237
Name:BANIPAL, AMRIT KAUR
Entity type:Individual
Prefix:
First Name:AMRIT
Middle Name:KAUR
Last Name:BANIPAL
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 1:1935 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-3983
Mailing Address - Country:US
Mailing Address - Phone:773-701-3074
Mailing Address - Fax:
Practice Address - Street 1:20 BOULDER HILL PASS
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-1951
Practice Address - Country:US
Practice Address - Phone:630-896-5013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190328401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty