Provider Demographics
NPI:1275848350
Name:GUPTA, VIJAYATA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:VIJAYATA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:VIJAYATA
Other - Middle Name:
Other - Last Name:MANUBALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:15100 W. LIBRARY LN.
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151
Mailing Address - Country:US
Mailing Address - Phone:262-641-0056
Mailing Address - Fax:262-641-0058
Practice Address - Street 1:15100 W. LIBRARY LN.
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151
Practice Address - Country:US
Practice Address - Phone:262-641-0056
Practice Address - Fax:262-641-0058
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010202811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice