Basic Information
| Provider Information | |||||||||
| NPI: | 1033576590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEGDE | ||||||||
| FirstName: | KIRANKUMAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 CITRINE PASS | ||||||||
| Address2: | 1-136 | ||||||||
| City: | HALTOM CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761377073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083081165 | ||||||||
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| Practice Location | |||||||||
| Address1: | 708 PALUXY RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GRANBURY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760482396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175734600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2016 | ||||||||
| LastUpdateDate: | 08/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 31650 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.