Provider Demographics
NPI:1699176990
Name:KOPURI, AVANTHI (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:AVANTHI
Middle Name:
Last Name:KOPURI
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 W NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3701
Mailing Address - Country:US
Mailing Address - Phone:321-728-9999
Mailing Address - Fax:
Practice Address - Street 1:2555 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3701
Practice Address - Country:US
Practice Address - Phone:321-728-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-06
Last Update Date:2020-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN190531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics