Provider Demographics
NPI:1871606558
Name:GUPTA, RADHESHYAM R (DDS)
Entity type:Individual
Prefix:
First Name:RADHESHYAM
Middle Name:R
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 1:7597 MORGAN ROAD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3538
Mailing Address - Country:US
Mailing Address - Phone:315-457-0322
Mailing Address - Fax:315-457-8237
Practice Address - Street 1:7597 MORGAN ROAD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3538
Practice Address - Country:US
Practice Address - Phone:315-457-0322
Practice Address - Fax:315-457-8237
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034890 1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00598178Medicaid