Provider Demographics
NPI:1891556502
Name:SUPER SMILES MARICOPA PLLC
Entity Type:Organization
Organization Name:SUPER SMILES MARICOPA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIKITA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUPPANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-568-3828
Mailing Address - Street 1:21116 N JOHN WAYNE PKWY STE B7
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-2932
Mailing Address - Country:US
Mailing Address - Phone:520-568-3828
Mailing Address - Fax:520-568-0443
Practice Address - Street 1:21116 N JOHN WAYNE PKWY STE B7
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-2932
Practice Address - Country:US
Practice Address - Phone:520-568-3828
Practice Address - Fax:520-568-0443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty