Basic Information
| Provider Information | |||||||||
| NPI: | 1952670432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | ABHISHEK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 735 HARRISON AVE | ||||||||
| Address2: | APT W103 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177638438 | ||||||||
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| Practice Location | |||||||||
| Address1: | 208 MAIN ST | ||||||||
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| City: | MILFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017572502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2011 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 12958 | CT | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | DN1857049 | MA | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 11011129A | 05 | MA | MEDICAID |