Provider Demographics
NPI:1457739971
Name:GOEL, KANU PRIYA
Entity Type:Individual
Prefix:
First Name:KANU PRIYA
Middle Name:
Last Name:GOEL
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 1:236 LAGRANGE COURT 236 LAGRANGE COURT
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210
Mailing Address - Country:US
Mailing Address - Phone:718-920-4321
Mailing Address - Fax:
Practice Address - Street 1:201 NEWNAN CROSSING BYPASS
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2401
Practice Address - Country:US
Practice Address - Phone:678-621-6410
Practice Address - Fax:678-423-0228
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0153121223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program