Provider Demographics
NPI:1770612285
Name:KOPURI, NAGESWARA RAO (BDS,MS)
Entity type:Individual
Prefix:DR
First Name:NAGESWARA
Middle Name:RAO
Last Name:KOPURI
Suffix:
Gender:M
Credentials:BDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 HAWKSBILL ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3851
Mailing Address - Country:US
Mailing Address - Phone:321-427-3000
Mailing Address - Fax:321-728-4925
Practice Address - Street 1:2555 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3701
Practice Address - Country:US
Practice Address - Phone:321-728-9999
Practice Address - Fax:321-728-4925
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 105521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics