Provider Demographics
NPI:1093974867
Name:GOPALA KRISHNAN, DEEPAK (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEEPAK
Middle Name:
Last Name:GOPALA KRISHNAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 630579
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0579
Mailing Address - Country:US
Mailing Address - Phone:513-585-5501
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:222 PIEDMONT AVE
Practice Address - Street 2:STE. 7300
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-4231
Practice Address - Country:US
Practice Address - Phone:513-475-8783
Practice Address - Fax:513-475-7698
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH71.0002161223S0112X
OH710002161223S0112X
OH30-024214204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2900874Medicaid
OH2900874Medicaid