MEDICARE: MAA CRYSTAL DENTAL

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	122300000X	Dentist

General Provider Information

NPI Number	:	1235922659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAA CRYSTAL DENTAL

Provider Business Mailing Address
First Line	:	402 E ZAVALA ST STE 1
Second Line	:
City	:	CRYSTAL CITY
State	:	TX
Zip	:	78839-3337
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 E ZAVALA ST STE 1
Second Line	:
City	:	CRYSTAL CITY
State	:	TX
Zip	:	78839-3337
Country	:	US
Telephone Number	:	661-618-4215
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. VE N K A T A R A J E S H K U M A R P A S U P ULE TI
Credential	:
Telephone Number	:	661-618-4215

Provider Enumeration Date	:	05/28/2025
Last Update Date	:	05/28/2025

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Directions to “MAA CRYSTAL DENTAL ” Practice Location

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