MEDICARE: DR. RADHA KRISHNAN DMD, MS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	11601	MD

General Provider Information

NPI Number	:	1770586596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RADHA KRISHNAN DMD, MS

Provider Business Mailing Address
First Line	:	10223 BRITTENFORD DR
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-1867
Country	:	US
Telephone Number	:	703-405-7833
Fax Number	:

Provider Business Practice Location Address
First Line	:	294 MERRIMAC CT
Second Line	:	STE 294
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-4110
Country	:	US
Telephone Number	:	410-535-2332
Fax Number	:	410-535-6922

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/08/2007

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