Provider Demographics
NPI:1649648668
Name:KUPPANDA, NIKITA
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:KUPPANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4368122300000X
AZ103161223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist