Healthcare Provider Details

I. General information

NPI: 1437805272
Provider Name (Legal Business Name): MANJUSHA KUPPADAKATH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32530 SHIELA WAY
UNION CITY CA
94587-5048
US

IV. Provider business mailing address

32530 SHIELA WAY
UNION CITY CA
94587-5048
US

V. Phone/Fax

Practice location:
  • Phone: 408-313-6090
  • Fax:
Mailing address:
  • Phone: 408-313-6090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberHAP891
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number26210
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: