Healthcare Provider Details

I. General information

NPI: 1033576590
Provider Name (Legal Business Name): KIRANKUMAR HEGDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 PALUXY RD SUITE B
GRANBURY TX
76048-2396
US

IV. Provider business mailing address

3901 CITRINE PASS 1-136
HALTOM CITY TX
76137-7073
US

V. Phone/Fax

Practice location:
  • Phone: 817-573-4600
  • Fax:
Mailing address:
  • Phone: 508-308-1165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number31650
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: