=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275188930
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARL SUPAL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2019
-----------------------------------------------------
Last Update Date | 01/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 99 3RD ST
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94022-2729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-949-3376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 1ST ST UNIT 307
-----------------------------------------------------
City | LOS ALTOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94022-2689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-929-4569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DDS103819
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------