Healthcare Provider Details

I. General information

NPI: 1518215615
Provider Name (Legal Business Name): SUPRITHA HANGAL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 ANDREWS HWY SUITE 400
MIDLAND TX
79701-3896
US

IV. Provider business mailing address

2050 E ALGONQUIN RD 610
SCHAUMBURG IL
60173-4144
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-4066
  • Fax: 847-496-7603
Mailing address:
  • Phone: 888-988-4066
  • Fax: 847-496-7603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.029217
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: