=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194379271
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAI KRISHNA SRIKANTH KOLLIBOYANA DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2019
-----------------------------------------------------
Last Update Date | 01/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4403 SHERWOOD WAY
-----------------------------------------------------
City | SAN ANGELO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76901-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-308-6337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4300 CROMWELL DR APT 3210
-----------------------------------------------------
City | KYLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78640-6496
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-423-4811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.032253
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 36098
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------