Basic Information
| Provider Information | |||||||||
| NPI: | 1659821502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | NEHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 NORTHEASTERN BLVD | ||||||||
| Address2: | STE C | ||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030623128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038823616 | ||||||||
| FaxNumber: | 6035957414 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038216122 | ||||||||
| FaxNumber: | 6038215620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 04263 | MA | N | Dental Providers | Dentist | 122300000X | 4263 | NH | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 3107123 | 05 | NH | MEDICAID |