Healthcare Provider Details

I. General information

NPI: 1407112261
Provider Name (Legal Business Name): KUPCHIK DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEDICAL PARK DR SUITE 16
WEST NYACK NY
10994-1965
US

IV. Provider business mailing address

2 MEDICAL PARK DR SUITE 16
WEST NYACK NY
10994-1965
US

V. Phone/Fax

Practice location:
  • Phone: 213-479-9547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number055641-1
License Number StateNY

VIII. Authorized Official

Name: DR. ANNA KUPCHIK
Title or Position: DENTIST
Credential: DDS
Phone: 213-479-9547