Provider Demographics
NPI:1770833246
Name:SRILASIMHA
Entity Type:Organization
Organization Name:SRILASIMHA
Other - Org Name:KLEEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VAISHNAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:IYER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-247-7255
Mailing Address - Street 1:838 S CARRIER PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1517
Mailing Address - Country:US
Mailing Address - Phone:214-247-7255
Mailing Address - Fax:
Practice Address - Street 1:838 S CARRIER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1517
Practice Address - Country:US
Practice Address - Phone:214-247-7255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX212704505Medicaid
TX306940301Medicaid