Healthcare Provider Details

I. General information

NPI: 1497994917
Provider Name (Legal Business Name): JOSEPH GUPANA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2009
Last Update Date: 02/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N BROAD ST
PHILADELPHIA PA
19140-5007
US

IV. Provider business mailing address

3223 N BROAD ST
PHILADELPHIA PA
19140-5007
US

V. Phone/Fax

Practice location:
  • Phone: 630-779-7143
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS037540
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: