Healthcare Provider Details

I. General information

NPI: 1790212348
Provider Name (Legal Business Name): VIDUSHI GUPTA D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 S BROAD ST STE 2D
MERIDEN CT
06450-6601
US

IV. Provider business mailing address

546 S BROAD ST STE 2D
MERIDEN CT
06450-6601
US

V. Phone/Fax

Practice location:
  • Phone: 203-630-1312
  • Fax:
Mailing address:
  • Phone: 203-630-1312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12796
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: