=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891681359
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DHEERAJ KUMAR KOLI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2025
-----------------------------------------------------
Last Update Date | 06/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 534 10TH ST STE A1
-----------------------------------------------------
City | FLORESVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78114-3199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-275-9423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9914 W MILITARY DR APT 618
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78251-1799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-275-9423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 41442
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 41442
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------