Provider Demographics
NPI:1275151441
Name:KULLAR, PRIYA SAPRA
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:SAPRA
Last Name:KULLAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PRIYA
Other - Middle Name:
Other - Last Name:SAPRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 PARK PL
Mailing Address - Street 2:PROFESSIONAL CENTRE SUITE B
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-234-5533
Mailing Address - Fax:618-234-8248
Practice Address - Street 1:16 PARK PL STE B
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2928
Practice Address - Country:US
Practice Address - Phone:618-234-5533
Practice Address - Fax:618-234-8248
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019032757122300000X
IL0210032181223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist