Provider Demographics
NPI:1245469618
Name:KOPPURAVURI, VENKATASUMAN (DDS)
Entity type:Individual
Prefix:
First Name:VENKATASUMAN
Middle Name:
Last Name:KOPPURAVURI
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 1:2298 CHERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732
Mailing Address - Country:US
Mailing Address - Phone:038-980-7937
Mailing Address - Fax:
Practice Address - Street 1:3010 LBJ FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-2723
Practice Address - Country:US
Practice Address - Phone:972-444-8888
Practice Address - Fax:972-243-6059
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246991223G0001X
OH30.0233621223G0001X
NC106231223G0001X
SC100671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice