Provider Demographics
NPI:1184822496
Name:GUPTA, PREETI
Entity Type:Individual
Prefix:
First Name:PREETI
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 1:15-01 BROADWAY STE 18
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-6018
Mailing Address - Country:US
Mailing Address - Phone:201-475-1600
Mailing Address - Fax:
Practice Address - Street 1:15-01 BROADWAY STE 18
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6018
Practice Address - Country:US
Practice Address - Phone:201-475-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-08
Last Update Date:2012-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0515851223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry