Provider Demographics
NPI:1689035685
Name:KOPPUZHA, DIANA (DMD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KOPPUZHA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20389 INTERSTATE 35 STE 200
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-2039
Mailing Address - Country:US
Mailing Address - Phone:512-256-8754
Mailing Address - Fax:
Practice Address - Street 1:20389 INTERSTATE 35 STE 200
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-2039
Practice Address - Country:US
Practice Address - Phone:512-256-8754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice