Provider Demographics
NPI:1346697307
Name:FOSSIL RIDGE FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:FOSSIL RIDGE FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISHNA
Authorized Official - Middle Name:P
Authorized Official - Last Name:COLLURU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-469-7076
Mailing Address - Street 1:7332 SAN FELIPE DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-3356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 N TARRANT PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5410
Practice Address - Country:US
Practice Address - Phone:201-469-7076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24625122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty