Healthcare Provider Details

I. General information

NPI: 1215691316
Provider Name (Legal Business Name): PRAFULL DAS GUPTA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 S BURLINGTON BLVD
BURLINGTON WA
98233-1708
US

IV. Provider business mailing address

1101-1473 JOHNSTON RD
WHITE ROCK BRITISH COLUMBIA
V4B 0A2
CA

V. Phone/Fax

Practice location:
  • Phone: 360-707-5353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE61212830
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: