Provider Demographics
NPI:1417346727
Name:KOPERLY, MOSTAFA
Entity type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:
Last Name:KOPERLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17113 ARROW BLVD
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3948
Mailing Address - Country:US
Mailing Address - Phone:832-436-8277
Mailing Address - Fax:
Practice Address - Street 1:17113 ARROW BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3948
Practice Address - Country:US
Practice Address - Phone:832-436-8277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-10
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00202418122300000X
CA101047122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist