Provider Demographics
NPI:1538855598
Name:KURUKULASURIYA, ANISHA
Entity type:Individual
Prefix:DR
First Name:ANISHA
Middle Name:
Last Name:KURUKULASURIYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANISHA
Other - Middle Name:
Other - Last Name:SEBASTIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11761 CHIMINEAS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3613
Mailing Address - Country:US
Mailing Address - Phone:818-439-3524
Mailing Address - Fax:
Practice Address - Street 1:501 S ANGEL PKWY # 400
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-4800
Practice Address - Country:US
Practice Address - Phone:972-646-7774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX388181223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty