Provider Demographics
NPI:1790430189
Name:DESAI, KRISHNA H
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:H
Last Name:DESAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 BLACK MOUNTAIN CIR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-6530
Mailing Address - Country:US
Mailing Address - Phone:510-736-9890
Mailing Address - Fax:
Practice Address - Street 1:7584 E STATE ROUTE 69
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2278
Practice Address - Country:US
Practice Address - Phone:510-736-9890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.0134081122300000X
AZD0116851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicaid