Healthcare Provider Details

I. General information

NPI: 1699753319
Provider Name (Legal Business Name): SREENIVAS KOKA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BAKER BLVD
LELAND MS
38756-3401
US

IV. Provider business mailing address

201 BAKER BLVD
LELAND MS
38756-3401
US

V. Phone/Fax

Practice location:
  • Phone: 662-686-4121
  • Fax: 662-686-4770
Mailing address:
  • Phone: 662-686-4121
  • Fax: 662-686-4770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number63470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: