MEDICARE: KOPURI ORTHODONTIST PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN 10552	FL

General Provider Information

NPI Number	:	1316238439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOPURI ORTHODONTIST PA

Provider Business Mailing Address
First Line	:	726 HAWKSBILL ISLAND DR
Second Line	:
City	:	SATELLITE BCH
State	:	FL
Zip	:	32937-3851
Country	:	US
Telephone Number	:	321-427-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	990 N STATE ROAD 434
Second Line	:	SUITE# 1188
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-7035
Country	:	US
Telephone Number	:	407-682-0883
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. N RAO KOPURI
Credential	:	B.D.S.,M.S.
Telephone Number	:	321-427-3000

Provider Enumeration Date	:	04/23/2011
Last Update Date	:	04/23/2011

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