Provider Demographics
NPI:1427378314
Name:GUPTA, PRIYA (DMD)
Entity Type:Individual
Prefix:DR
First Name:PRIYA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12380 CLARETH DR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2015
Mailing Address - Country:US
Mailing Address - Phone:703-609-4144
Mailing Address - Fax:
Practice Address - Street 1:4001 LEGATO RD STE 203
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-4098
Practice Address - Country:US
Practice Address - Phone:703-385-7177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414357122300000X
MADN18553951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice