Provider Demographics
NPI:1881929552
Name:MISRA, RAJEEV (DDS)
Entity type:Individual
Prefix:DR
First Name:RAJEEV
Middle Name:
Last Name:MISRA
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 1:2140 E. SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE L-509
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-909-1023
Mailing Address - Fax:817-488-9685
Practice Address - Street 1:840 SIMMONS COURT
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-909-1023
Practice Address - Fax:817-488-9685
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX178591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice