Provider Demographics
NPI:1558062471
Name:VARDHAMAN, SONAJ
Entity type:Individual
Prefix:
First Name:SONAJ
Middle Name:
Last Name:VARDHAMAN
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 1:3300 E BROAD ST STE 120
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5630
Mailing Address - Country:US
Mailing Address - Phone:168-251-8585
Mailing Address - Fax:
Practice Address - Street 1:3300 E BROAD ST STE 120
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5630
Practice Address - Country:US
Practice Address - Phone:168-251-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX41613122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program