MEDICARE: DENESH K KHULLAR DDS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3448	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5Y667	OTHER	AR	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1124351150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENESH K KHULLAR DDS PA

Provider Business Mailing Address
First Line	:	PO BOX 241763
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72223-0014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2524 CRESTWOOD RD STE 2
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7648
Country	:	US
Telephone Number	:	501-753-7366
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DENESH KHULLAR
Credential	:	D.D.S.
Telephone Number	:	501-753-7366

Provider Enumeration Date	:	09/09/2009
Last Update Date	:	09/09/2009

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