MEDICARE: KB DENTISTRY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1821553447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KB DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	2712 SW 29TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73119-1806
Country	:	US
Telephone Number	:	405-212-4549
Fax Number	:	405-212-4548

Provider Business Practice Location Address
First Line	:	2712 SW 29TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73119-1806
Country	:	US
Telephone Number	:	405-212-4549
Fax Number	:	405-212-4548

Authorized Official
Title or Position	:	OWNER
Name	:	ANUSHA KONERU
Credential	:	DDS
Telephone Number	:	405-212-4549

Provider Enumeration Date	:	02/07/2019
Last Update Date	:	06/11/2019

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