Provider Demographics
NPI:1477696953
Name:GUPTA, POONAM G (DDS)
Entity Type:Individual
Prefix:DR
First Name:POONAM
Middle Name:G
Last Name:GUPTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182
Mailing Address - Country:US
Mailing Address - Phone:734-847-9905
Mailing Address - Fax:734-847-1848
Practice Address - Street 1:7960 LEWIS AVENUE
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182
Practice Address - Country:US
Practice Address - Phone:734-847-9905
Practice Address - Fax:734-847-1848
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18523122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist