Healthcare Provider Details

I. General information

NPI: 1922051895
Provider Name (Legal Business Name): JOEL A SUPITA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 N US HIGHWAY 141
CRIVITZ WI
54114-1639
US

IV. Provider business mailing address

W7592 E 26TH RD
CRIVITZ WI
54114-7366
US

V. Phone/Fax

Practice location:
  • Phone: 715-854-7545
  • Fax:
Mailing address:
  • Phone: 715-854-7409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2824-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: