Provider Demographics
NPI:1699753319
Name:KOKA, SREENIVAS (DDS)
Entity type:Individual
Prefix:
First Name:SREENIVAS
Middle Name:
Last Name:KOKA
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 1:201 BAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756-3401
Mailing Address - Country:US
Mailing Address - Phone:662-686-4121
Mailing Address - Fax:662-686-4770
Practice Address - Street 1:201 BAKER BLVD
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:MS
Practice Address - Zip Code:38756-3401
Practice Address - Country:US
Practice Address - Phone:662-686-4121
Practice Address - Fax:662-686-4770
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA634701223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN587433500Medicaid
WI33828500Medicaid
MNP00918769OtherRAILROAD MEDICARE
U24871Medicare UPIN
WI33828500Medicaid