Healthcare Provider Details

I. General information

NPI: 1730628587
Provider Name (Legal Business Name): SUPRIYA KOIRALA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86-260 FARRINGTON HWY
WAIANAE HI
96792-3128
US

IV. Provider business mailing address

1650 ALA MOANA BLVD APT 1909
HONOLULU HI
96815-1412
US

V. Phone/Fax

Practice location:
  • Phone: 808-697-3496
  • Fax:
Mailing address:
  • Phone: 303-503-7818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDTT292
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: