Healthcare Provider Details

I. General information

NPI: 1851528939
Provider Name (Legal Business Name): SABINA GUPTA SUD D.M.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SABINA GUPTA D.M.D., M.S.

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 WASHINGTON ST STE B
PETALUMA CA
94952-2914
US

IV. Provider business mailing address

301 WASHINGTON ST STE B
PETALUMA CA
94952-2914
US

V. Phone/Fax

Practice location:
  • Phone: 707-658-2320
  • Fax: 707-762-5149
Mailing address:
  • Phone: 707-658-2320
  • Fax: 707-762-5149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number64213
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN013884
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: