=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558730416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAPPY FACES KIDS & FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2015
-----------------------------------------------------
Last Update Date | 09/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 N MAIN ST 10
-----------------------------------------------------
City | FLORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62839-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-662-2025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 N MAIN ST
-----------------------------------------------------
City | FLORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62839-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KRISHNA GORANTLA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 812-229-2675
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.030203
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------