Provider Demographics
NPI:1922051895
Name:SUPITA, JOEL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:A
Last Name:SUPITA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W7592 E 26TH RD
Mailing Address - Street 2:
Mailing Address - City:CRIVITZ
Mailing Address - State:WI
Mailing Address - Zip Code:54114-7366
Mailing Address - Country:US
Mailing Address - Phone:715-854-7409
Mailing Address - Fax:
Practice Address - Street 1:519 N US HIGHWAY 141
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114-1639
Practice Address - Country:US
Practice Address - Phone:715-854-7545
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2824-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice