Provider Demographics
NPI:1790212348
Name:GUPTA, VIDUSHI (DMD)
Entity Type:Individual
Prefix:DR
First Name:VIDUSHI
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 1:546 S BROAD ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6601
Mailing Address - Country:US
Mailing Address - Phone:203-630-1312
Mailing Address - Fax:
Practice Address - Street 1:546 S BROAD ST STE 2D
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6601
Practice Address - Country:US
Practice Address - Phone:203-630-1312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT127961223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program