Healthcare Provider Details

I. General information

NPI: 1174079305
Provider Name (Legal Business Name): PREETHI KUKNOORU DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 LOCKHILL SELMA RD STE 101
SHAVANO PARK TX
78249-4394
US

IV. Provider business mailing address

4450 LOCKHILL SELMA RD STE 101
SHAVANO PARK TX
78249-4394
US

V. Phone/Fax

Practice location:
  • Phone: 408-981-4640
  • Fax:
Mailing address:
  • Phone: 408-981-4640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number368-83
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019030943
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: