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General NPI Number Information
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NPI Number | 1861896474
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Entity Type | Organization
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Legal Business Name | AVANTHI KOPURI, DMD, MSD, MHA, PLLC
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Dates
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Enumeration Date | 10/13/2014
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Last Update Date | 08/28/2020
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Provider Practice Location Address
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Address Line | 3010 S FISKE BLVD
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City | ROCKLEDGE
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State | FL
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Zip | 32955-4302
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Country | US
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Telephone | 321-638-4455
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Fax | 321-638-1203
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Provider Business Mailing Address
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Address Line | 3010 S FISKE BLVD
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City | ROCKLEDGE
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State | FL
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Zip | 32955-4302
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Country | US
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Telephone | 321-638-4455
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Fax | 321-638-1203
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. AVANTHI KOPURI
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Credential | DMD, MSD, MHA
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Telephone | 305-788-4415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | P00000094134
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License Number State | FL
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