Provider Demographics
NPI:1629597562
Name:NILAM, SUPRITHA (DDS)
Entity Type:Individual
Prefix:
First Name:SUPRITHA
Middle Name:
Last Name:NILAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10833 LE CONTE AVENUE, A0156 CHS
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095
Mailing Address - Country:US
Mailing Address - Phone:310-825-0834
Mailing Address - Fax:310-794-2198
Practice Address - Street 1:72 BEECHLAND RD
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-2533
Practice Address - Country:US
Practice Address - Phone:207-667-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN45891223G0001X
CA106194204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice