Provider Demographics
NPI:1588649818
Name:KRISHNAN, VASANTI (DDS)
Entity Type:Individual
Prefix:DR
First Name:VASANTI
Middle Name:
Last Name:KRISHNAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-4802
Mailing Address - Country:US
Mailing Address - Phone:718-384-6455
Mailing Address - Fax:718-599-6379
Practice Address - Street 1:614 GRAND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4802
Practice Address - Country:US
Practice Address - Phone:718-384-6455
Practice Address - Fax:718-599-6379
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0380181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00803567Medicaid