Healthcare Provider Details

I. General information

NPI: 1689798142
Provider Name (Legal Business Name): AVANTHI KOPURI, DMD, MSD, MHA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 SAND LAKE RD SUITE 124
ORLANDO FL
32809-7750
US

IV. Provider business mailing address

730 SAND LAKE RD SUITE 124
ORLANDO FL
32809-7750
US

V. Phone/Fax

Practice location:
  • Phone: 407-850-2355
  • Fax: 407-850-2989
Mailing address:
  • Phone: 407-850-2355
  • Fax: 407-850-2989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberP00000094134
License Number StateFL

VIII. Authorized Official

Name: DR. AVANTHI KOPURI
Title or Position: PRESIDENT
Credential: DMD, MSD, MHA
Phone: 305-788-4415