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General NPI Number Information
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NPI Number | 1164952032
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Entity Type | Individual
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Provider Name | JACOB JOSE KURUVILLA DMD
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Gender | Male
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Dates
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Enumeration Date | 06/14/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1110 S CESAR CHAVEZ BLVD APT 3050
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City | DALLAS
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State | TX
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Zip | 75201-6089
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Country | US
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Telephone | 631-742-9840
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Fax |
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Provider Business Mailing Address
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Address Line | 11613 N CENTRAL EXPY STE 111A
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City | DALLAS
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State | TX
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Zip | 75243-3808
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Country | US
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Telephone | 631-742-9840
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS041245
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 33117
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License Number State | TX
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