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General NPI Number Information
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NPI Number | 1649648668
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Entity Type | Individual
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Provider Name | NIKITA KUPPANDA
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Gender | Female
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Dates
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Enumeration Date | 09/08/2015
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Last Update Date | 01/19/2024
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Provider Practice Location Address
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Address Line | 21116 N JOHN WAYNE PKWY STE B7
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City | MARICOPA
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State | AZ
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Zip | 85139-2932
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Country | US
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Telephone | 520-568-3828
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Fax | 520-568-0443
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Provider Business Mailing Address
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Address Line | 21116 N JOHN WAYNE PKWY STE B7
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City | MARICOPA
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State | AZ
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Zip | 85139-2932
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Country | US
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Telephone | 520-568-3828
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Fax | 520-568-0443
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD4368
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 10316
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License Number State | AZ
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