Provider Demographics
NPI:1649283284
Name:KRISHNA, DIVYA R (DMD)
Entity type:Individual
Prefix:
First Name:DIVYA
Middle Name:R
Last Name:KRISHNA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 N FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-8160
Mailing Address - Country:US
Mailing Address - Phone:847-740-4100
Mailing Address - Fax:847-740-4105
Practice Address - Street 1:732 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-8160
Practice Address - Country:US
Practice Address - Phone:847-740-4100
Practice Address - Fax:847-740-4105
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190271341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice