MEDICARE: PAUL K UPATHAM D.D.S., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	50006	CA

General Provider Information

NPI Number	:	1619136330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL K UPATHAM D.D.S., M.S.

Provider Business Mailing Address
First Line	:	1831 SUNSET CLIFFS BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3108
Country	:	US
Telephone Number	:	619-225-1611
Fax Number	:	619-225-9070

Provider Business Practice Location Address
First Line	:	1831 SUNSET CLIFFS BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3108
Country	:	US
Telephone Number	:	619-225-1611
Fax Number	:	619-225-9070

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2008
Last Update Date	:	06/06/2008

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