Provider Demographics
NPI:1972115202
Name:KALLARACKAL, BRIAN J (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:KALLARACKAL
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 1:239 ASPENWAY DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-5506
Mailing Address - Country:US
Mailing Address - Phone:940-337-8970
Mailing Address - Fax:
Practice Address - Street 1:239 ASPENWAY DR
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-5506
Practice Address - Country:US
Practice Address - Phone:940-337-8970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36576122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist