Provider Demographics
NPI:1952670432
Name:GUPTA, ABHISHEK
Entity Type:Individual
Prefix:
First Name:ABHISHEK
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 HARRISON AVE
Mailing Address - Street 2:APT W103
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4903
Mailing Address - Country:US
Mailing Address - Phone:617-763-8438
Mailing Address - Fax:
Practice Address - Street 1:208 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2502
Practice Address - Country:US
Practice Address - Phone:617-638-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT129581223S0112X
MADN18570491223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11011129AMedicaid