=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184928640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVIN GUPTA D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2010
-----------------------------------------------------
Last Update Date | 12/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 SPENCERPORT RD SUITE A4
-----------------------------------------------------
City | SPENCERPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14559-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-352-3627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 73 VISCOUNT DR
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-1766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-984-0145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 055323
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------