Provider Demographics
NPI:1841529211
Name:HEMINTAKOON, KRISDA TOM (DDS)
Entity type:Individual
Prefix:
First Name:KRISDA
Middle Name:TOM
Last Name:HEMINTAKOON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 DANEBURY DOWNS
Mailing Address - Street 2:
Mailing Address - City:UPPER SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-1507
Mailing Address - Country:US
Mailing Address - Phone:718-321-9870
Mailing Address - Fax:
Practice Address - Street 1:13705 FRANKLIN AVE STE L1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3801
Practice Address - Country:US
Practice Address - Phone:718-321-9870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0455661223G0001X
NJ22DI021984001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice