Healthcare Provider Details

I. General information

NPI: 1275640963
Provider Name (Legal Business Name): KRISHNAKAMAL C MEHTA BDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3641 CONNALLY DR
MARIANNA FL
32446-7972
US

IV. Provider business mailing address

3655 WEBB RD
MARIANNA FL
32446-8047
US

V. Phone/Fax

Practice location:
  • Phone: 321-634-6392
  • Fax:
Mailing address:
  • Phone: 915-235-1178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number10953
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: