MEDICARE: DR. COLLETTE ELKE SUPIT D.D.S.

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	122300000X	Dentist	D1001	GU

General Provider Information

NPI Number	:	1427475300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COLLETTE ELKE SUPIT D.D.S.

Provider Business Mailing Address
First Line	:	154 CALACHUCHA AVE
Second Line	:
City	:	BARRIGADA
State	:	GU
Zip	:	96913-1238
Country	:	US
Telephone Number	:	671-488-5976
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 CHALAN SAN ANTONIO
Second Line	:	SUITE 108
City	:	TAMUNING
State	:	GU
Zip	:	96913-3620
Country	:	US
Telephone Number	:	671-647-3526
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2014
Last Update Date	:	03/27/2014

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