Healthcare Provider Details

I. General information

NPI: 1689710287
Provider Name (Legal Business Name): MARTIN L. SUPOWITZ D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5433 WALNUT ST SUITE 200
PITTSBURGH PA
15232-3214
US

IV. Provider business mailing address

5433 WALNUT ST SUITE 200
PITTSBURGH PA
15232-3214
US

V. Phone/Fax

Practice location:
  • Phone: 412-687-3232
  • Fax: 412-535-0303
Mailing address:
  • Phone: 412-687-3232
  • Fax: 412-535-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS-022556-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: