Provider Demographics
NPI:1053037234
Name:GUPTA, BHASKAR (DDS)
Entity type:Individual
Prefix:
First Name:BHASKAR
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 WAYNE 216
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:MO
Mailing Address - Zip Code:63950-8726
Mailing Address - Country:US
Mailing Address - Phone:661-741-7929
Mailing Address - Fax:
Practice Address - Street 1:110 S 2ND ST
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638-9400
Practice Address - Country:US
Practice Address - Phone:573-663-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107390122300000X
MO20230441541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist