Healthcare Provider Details

I. General information

NPI: 1295046399
Provider Name (Legal Business Name): SHIVANE K GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 FIVE FORKS TRICKUM RD SW STE 1
LILBURN GA
30047-3130
US

IV. Provider business mailing address

4150 FIVE FORKS TRICKUM RD SW STE 1
LILBURN GA
30047-3130
US

V. Phone/Fax

Practice location:
  • Phone: 770-717-7225
  • Fax: 770-717-7228
Mailing address:
  • Phone: 770-717-7225
  • Fax: 770-717-7228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number078309
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: