Healthcare Provider Details

I. General information

NPI: 1821685041
Provider Name (Legal Business Name): ANISH GUPTA DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30770 LYON CENTER DR. EAST
NEW HUDSON MI
48165
US

IV. Provider business mailing address

6736 PORTSMAN CT
CANTON MI
48187-2176
US

V. Phone/Fax

Practice location:
  • Phone: 248-422-1555
  • Fax: 248-422-0755
Mailing address:
  • Phone: 248-895-1451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANISH GUPTA
Title or Position: OWNER, ORAL AND MAXILLOFACIAL SURGE
Credential: DDS
Phone: 248-895-1451