Provider Demographics
NPI:1073746822
Name:GUPTA, PREETIKA
Entity Type:Individual
Prefix:
First Name:PREETIKA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 STRAIGHT PATH
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-2407
Mailing Address - Country:US
Mailing Address - Phone:631-643-3800
Mailing Address - Fax:
Practice Address - Street 1:1595 STRAIGHT PATH
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-2407
Practice Address - Country:US
Practice Address - Phone:631-643-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0546411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice