Healthcare Provider Details

I. General information

NPI: 1144512583
Provider Name (Legal Business Name): KOPURI ORTHODONTIST PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TREEMONT DR
ORANGE CITY FL
32763-7945
US

IV. Provider business mailing address

726 HAWKSBILL ISLAND DR
SATELLITE BEACH FL
32937-3851
US

V. Phone/Fax

Practice location:
  • Phone: 386-775-8707
  • Fax:
Mailing address:
  • Phone: 321-427-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN 10552
License Number StateFL

VIII. Authorized Official

Name: DR. N RAO KOPURI
Title or Position: PRESIDENT
Credential: B.D.S.,M.S.
Phone: 321-427-3000