MEDICARE: KRIS DENTAL PC

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	0022113	TX

General Provider Information

NPI Number	:	1750690053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRIS DENTAL PC

Provider Business Mailing Address
First Line	:	1921 NORFOLK ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77098-4223
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1432 AUSTIN HWY
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-4902
Country	:	US
Telephone Number	:	210-822-5747
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SANJEEV GOPALAKRISHNAN
Credential	:	D.D.S
Telephone Number	:	210-822-5747

Provider Enumeration Date	:	10/04/2010
Last Update Date	:	05/19/2011

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