Provider Demographics
NPI:1730628587
Name:KOIRALA, SUPRIYA (DMD)
Entity type:Individual
Prefix:
First Name:SUPRIYA
Middle Name:
Last Name:KOIRALA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 ALA MOANA BLVD APT 1909
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-1412
Mailing Address - Country:US
Mailing Address - Phone:303-503-7818
Mailing Address - Fax:
Practice Address - Street 1:86-260 FARRINGTON HWY
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3128
Practice Address - Country:US
Practice Address - Phone:808-697-3496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO390200000X
HIDTT292122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty