Provider Demographics
NPI:1275188930
Name:SUPAL, KARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:
Last Name:SUPAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 1ST ST UNIT 307
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-2689
Mailing Address - Country:US
Mailing Address - Phone:586-929-4569
Mailing Address - Fax:
Practice Address - Street 1:99 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-2729
Practice Address - Country:US
Practice Address - Phone:650-949-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1038191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice