Healthcare Provider Details

I. General information

NPI: 1912427766
Provider Name (Legal Business Name): PRATIK VINODKUMAR GUPTA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W NC HIGHWAY 54 STE 201
DURHAM NC
27713-7564
US

IV. Provider business mailing address

602 GABRIELINO DR
IRVINE CA
92617-4107
US

V. Phone/Fax

Practice location:
  • Phone: 919-205-2216
  • Fax: 919-590-1711
Mailing address:
  • Phone: 817-896-2865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1001615
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11217
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105850
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: