Basic Information
| Provider Information | |||||||||
| NPI: | 1780737627 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | NIDHI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 749 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056610749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028518603 | ||||||||
| FaxNumber: | 8028518313 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 W BLUE RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641451216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136696129 | ||||||||
| FaxNumber: | 9132816405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 2019002294 | MO | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1014638 | 05 | VT | MEDICAID | 432249499 | 05 | ME | MEDICAID | 47D0660981 | 05 | VT | MEDICAID | 1780737627 | 01 | MO | NPI | OTHER |