MEDICARE: DR. KRISHNA PRASAD COLLURU DDS

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	24625	TX

General Provider Information

NPI Number	:	1750539490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISHNA PRASAD COLLURU DDS

Provider Business Mailing Address
First Line	:	3900 N TARRANT PKWY
Second Line	:	100
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5410
Country	:	US
Telephone Number	:	817-379-9091
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 N TARRANT PKWY
Second Line	:	100
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5410
Country	:	US
Telephone Number	:	817-379-9091
Fax Number	:

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

Provider Enumeration Date	:	09/07/2008
Last Update Date	:	12/21/2016

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