Provider Demographics
NPI:1811300460
Name:NAMSUPAK, AMY (DDS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:NAMSUPAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 WALTHAM WAY
Mailing Address - Street 2:APT 201
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4077
Mailing Address - Country:US
Mailing Address - Phone:304-993-1616
Mailing Address - Fax:
Practice Address - Street 1:2100 LYNNHAVEN PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-1492
Practice Address - Country:US
Practice Address - Phone:757-961-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014152771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry