Provider Demographics
NPI:1437805272
Name:KUPPADAKATH, MANJUSHA
Entity Type:Individual
Prefix:
First Name:MANJUSHA
Middle Name:
Last Name:KUPPADAKATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32530 SHIELA WAY
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-5048
Mailing Address - Country:US
Mailing Address - Phone:408-313-6090
Mailing Address - Fax:
Practice Address - Street 1:32530 SHIELA WAY
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-5048
Practice Address - Country:US
Practice Address - Phone:408-313-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP891124Q00000X
CA26210124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist