Provider Demographics
NPI:1275838328
Name:GOPISETTY, KRISHNA M (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:M
Last Name:GOPISETTY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2147
Mailing Address - Country:US
Mailing Address - Phone:773-276-5566
Mailing Address - Fax:
Practice Address - Street 1:1738 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2147
Practice Address - Country:US
Practice Address - Phone:773-276-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029636122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist