Provider Demographics
NPI:1881904084
Name:TINA GUPTA DDS PA II
Entity type:Organization
Organization Name:TINA GUPTA DDS PA II
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:252-572-2520
Mailing Address - Street 1:451 RUIN CREEK RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2878
Mailing Address - Country:US
Mailing Address - Phone:252-572-2520
Mailing Address - Fax:252-572-2527
Practice Address - Street 1:451 RUIN CREEK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2878
Practice Address - Country:US
Practice Address - Phone:252-572-2520
Practice Address - Fax:252-572-2527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914161Medicaid