Healthcare Provider Details

I. General information

NPI: 1750990164
Provider Name (Legal Business Name): DIWAKAR KINRA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 GATEWAY CTR STE F
FLINT MI
48507-3992
US

IV. Provider business mailing address

5409 GATEWAY CTR STE F
FLINT MI
48507-3992
US

V. Phone/Fax

Practice location:
  • Phone: 810-235-0100
  • Fax:
Mailing address:
  • Phone: 810-235-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: CRISTINA A BAGWELL
Title or Position: PATIENT COORDINATOR
Credential:
Phone: 810-235-0100