Healthcare Provider Details

I. General information

NPI: 1629104278
Provider Name (Legal Business Name): VIDYA MADHURI KOPPINEEDI D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7836 NE SANDY BLVD
PORTLAND OR
97213-6467
US

IV. Provider business mailing address

7844 SW ALDER ST
TIGARD OR
97224-7240
US

V. Phone/Fax

Practice location:
  • Phone: 503-288-3107
  • Fax:
Mailing address:
  • Phone: 503-432-0919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8689
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: