MEDICARE: NISHA PUNJABI GUPTA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	30-022075	OH

General Provider Information

NPI Number	:	1770629024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NISHA PUNJABI GUPTA DDS

Provider Business Mailing Address
First Line	:	35201 EMORY DR
Second Line	:
City	:	AVON
State	:	OH
Zip	:	44011-4932
Country	:	US
Telephone Number	:	734-417-2781
Fax Number	:	440-327-1326

Provider Business Practice Location Address
First Line	:	34100 CENTER RIDGE RD
Second Line	:
City	:	NORTH RIDGEVILLE
State	:	OH
Zip	:	44039-5311
Country	:	US
Telephone Number	:	440-327-0027
Fax Number	:	440-327-0027

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	10/18/2018

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