Provider Demographics
NPI:1417249855
Name:KOPURI ORTHODONTIST PA
Entity Type:Organization
Organization Name:KOPURI ORTHODONTIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:N
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:KOPURI
Authorized Official - Suffix:
Authorized Official - Credentials:BDS,MS
Authorized Official - Phone:321-427-3000
Mailing Address - Street 1:726 HAWKSBILL ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3851
Mailing Address - Country:US
Mailing Address - Phone:321-427-3000
Mailing Address - Fax:
Practice Address - Street 1:2900 DAVID WALKER DR
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6177
Practice Address - Country:US
Practice Address - Phone:352-589-5558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 105521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty