Provider Demographics
NPI:1023881828
Name:GUPTA, SHIVANI
Entity type:Individual
Prefix:
First Name:SHIVANI
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4483 S WILDFLOWER PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4855 E WARNER RD UNIT B9
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-3308
Practice Address - Country:US
Practice Address - Phone:480-424-4890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011835122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist