=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275339178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGHANA GUPTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2025
-----------------------------------------------------
Last Update Date | 02/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1685 E HOME AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93728-2027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-218-9338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2134 N OSMUN AVE
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93619-7453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.033398
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------