Healthcare Provider Details

I. General information

NPI: 1649648668
Provider Name (Legal Business Name): NIKITA KUPPANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21116 N JOHN WAYNE PKWY STE B7
MARICOPA AZ
85139-2932
US

IV. Provider business mailing address

21116 N JOHN WAYNE PKWY STE B7
MARICOPA AZ
85139-2932
US

V. Phone/Fax

Practice location:
  • Phone: 520-568-3828
  • Fax: 520-568-0443
Mailing address:
  • Phone: 520-568-3828
  • Fax: 520-568-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4368
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10316
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: