Provider Demographics
NPI:1881693067
Name:SHETTY, SUPRIYA K (DDS)
Entity type:Individual
Prefix:
First Name:SUPRIYA
Middle Name:K
Last Name:SHETTY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SUPRIYA
Other - Middle Name:K
Other - Last Name:BHANDARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:21675 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2010
Mailing Address - Country:US
Mailing Address - Phone:262-798-8870
Mailing Address - Fax:262-798-8810
Practice Address - Street 1:21675 LONGVIEW DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2010
Practice Address - Country:US
Practice Address - Phone:262-798-8870
Practice Address - Fax:262-798-8810
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI59141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice