Healthcare Provider Details

I. General information

NPI: 1205523206
Provider Name (Legal Business Name): POOJA KRISHNASWAMY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4553 GLENCOE AVE STE 310
MARINA DEL REY CA
90292-7906
US

IV. Provider business mailing address

3913 VENETO CIR
LEANDER TX
78641-3720
US

V. Phone/Fax

Practice location:
  • Phone: 310-412-9291
  • Fax:
Mailing address:
  • Phone: 512-810-8149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS110388
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: