Provider Demographics
NPI:1689097107
Name:GUPTA DENTAL CORPORATION
Entity Type:Organization
Organization Name:GUPTA DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUGAL
Authorized Official - Middle Name:KISHORE
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-355-1485
Mailing Address - Street 1:11623 CHERRY AVE
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-1212
Mailing Address - Country:US
Mailing Address - Phone:909-355-1485
Mailing Address - Fax:909-355-2715
Practice Address - Street 1:11623 CHERRY AVE
Practice Address - Street 2:SUITE B-2
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-1212
Practice Address - Country:US
Practice Address - Phone:909-355-1485
Practice Address - Fax:909-355-2715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty