Provider Demographics
NPI:1104141316
Name:SCHUPPET DENTAL CORPORATION
Entity type:Organization
Organization Name:SCHUPPET DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCHUPPERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:949-863-9620
Mailing Address - Street 1:20062 SW BIRCH ST STE 220
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1519
Mailing Address - Country:US
Mailing Address - Phone:949-863-9620
Mailing Address - Fax:949-271-4931
Practice Address - Street 1:12791 NEWPORT AVE STE 208
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-8023
Practice Address - Country:US
Practice Address - Phone:714-544-1740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA543241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty