Healthcare Provider Details

I. General information

NPI: 1235717570
Provider Name (Legal Business Name): GUPTA FAMILY DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 ASSEMBLY DR STE 101
MENDON NY
14506-9604
US

IV. Provider business mailing address

PO BOX 455
MENDON NY
14506-0455
US

V. Phone/Fax

Practice location:
  • Phone: 585-624-5480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BHUMIJA GUPTA
Title or Position: OWNER
Credential:
Phone: 585-436-1640