Healthcare Provider Details

I. General information

NPI: 1902482003
Provider Name (Legal Business Name): DANIEL KURUVILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2021
Last Update Date: 09/01/2023
Certification Date: 08/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463725 STATE ROAD 200 STE 3
YULEE FL
32097-8671
US

IV. Provider business mailing address

625 ELMWOOD AVE
ROCHESTER NY
14620-2913
US

V. Phone/Fax

Practice location:
  • Phone: 904-584-9004
  • Fax: 904-347-2611
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN26484
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: