Basic Information
Provider Information | |||||||||
NPI: | 1730628587 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOIRALA | ||||||||
FirstName: | SUPRIYA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1650 ALA MOANA BLVD APT 1909 | ||||||||
Address2: |   | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968151412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3035037818 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 86-260 FARRINGTON HWY | ||||||||
Address2: |   | ||||||||
City: | WAIANAE | ||||||||
State: | HI | ||||||||
PostalCode: | 967923128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086973496 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2017 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   | MO | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 122300000X | DTT292 | HI | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.