Provider Demographics
NPI:1518576933
Name:BANSAL, SONAM
Entity type:Individual
Prefix:
First Name:SONAM
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 1:12368 STATE ROAD 535
Mailing Address - Street 2:#249
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836
Mailing Address - Country:US
Mailing Address - Phone:773-899-2917
Mailing Address - Fax:
Practice Address - Street 1:500 N SEMORAN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3381
Practice Address - Country:US
Practice Address - Phone:407-277-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25757122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist