=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841505344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRABHA KRISHNAN DDS P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2010
-----------------------------------------------------
Last Update Date | 08/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110-45 QUEENS BOULEVARD SUITE #108
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-5501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-268-5777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110-45 QUEENS BOULEVARD SUITE #108
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-5501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-268-5777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PRABHA KRISHNAN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 718-268-5777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 043558
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------