MEDICARE: DR. KRISHNA M GOPISETTY D.D.S., M.S.

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	019029636	IL

General Provider Information

NPI Number	:	1275838328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISHNA M GOPISETTY D.D.S., M.S.

Provider Business Mailing Address
First Line	:	1738 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2147
Country	:	US
Telephone Number	:	773-276-5566
Fax Number	:

Provider Business Practice Location Address
First Line	:	1738 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2147
Country	:	US
Telephone Number	:	773-276-5566
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2011
Last Update Date	:	09/29/2014

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