Healthcare Provider Details

I. General information

NPI: 1518251230
Provider Name (Legal Business Name): ANISH GUPTA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 03/08/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30770 LYON CENTER DRIVE EAST
NEW HUDSON MI
48165
US

IV. Provider business mailing address

30770 LYON CENTER DRIVE EAST
NEW HUDSON MI
48165
US

V. Phone/Fax

Practice location:
  • Phone: 248-422-1555
  • Fax: 248-422-0755
Mailing address:
  • Phone: 248-422-1555
  • Fax: 248-422-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901020371
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901020371
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: