Provider Demographics
NPI:1689056889
Name:CHUPP, JOSHUA (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:
Last Name:CHUPP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1384 SW ST. LUCIE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST. LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986
Mailing Address - Country:US
Mailing Address - Phone:772-249-0488
Mailing Address - Fax:
Practice Address - Street 1:1384 SW ST. LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986
Practice Address - Country:US
Practice Address - Phone:772-249-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist