Healthcare Provider Details

I. General information

NPI: 1699176990
Provider Name (Legal Business Name): AVANTHI KOPURI D.M.D., M.S.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2014
Last Update Date: 01/01/2020
Certification Date: 01/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 W NEW HAVEN AVE
MELBOURNE FL
32904-3701
US

IV. Provider business mailing address

2555 W NEW HAVEN AVE
MELBOURNE FL
32904-3701
US

V. Phone/Fax

Practice location:
  • Phone: 321-728-9999
  • Fax:
Mailing address:
  • Phone: 321-728-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN19053
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: