Provider Demographics
NPI:1649309071
Name:AVANTHI KOPURI, DMD, MSD, MHA, PLLC
Entity type:Organization
Organization Name:AVANTHI KOPURI, DMD, MSD, MHA, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AVANTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPURI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD, MHA
Authorized Official - Phone:305-788-4415
Mailing Address - Street 1:2555 W NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3701
Mailing Address - Country:US
Mailing Address - Phone:321-728-9999
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP000000941341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty