Provider Demographics
NPI:1841789245
Name:KUPERAVAGE, BROOKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:
Last Name:KUPERAVAGE
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:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:CUMBOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17930-0008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 GETTYSBURG PIKE STE B400
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-5207
Practice Address - Country:US
Practice Address - Phone:717-963-3198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0416451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS041645OtherSTATE LICENSE