Healthcare Provider Details

I. General information

NPI: 1093974867
Provider Name (Legal Business Name): DEEPAK GOPALA KRISHNAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 PIEDMONT AVE STE. 7300
CINCINNATI OH
45219-4231
US

IV. Provider business mailing address

PO BOX 630579
CINCINNATI OH
45263-0579
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8783
  • Fax: 513-475-7698
Mailing address:
  • Phone: 513-585-5501
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number71.000216
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number71000216
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number30-024214
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: