Provider Demographics
NPI:1861896474
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 1:3010 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4302
Mailing Address - Country:US
Mailing Address - Phone:321-638-4455
Mailing Address - Fax:321-638-1203
Practice Address - Street 1:3010 S FISKE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-4302
Practice Address - Country:US
Practice Address - Phone:321-638-4455
Practice Address - Fax:321-638-1203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
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