Provider Demographics
NPI:1194894626
Name:GUPTA, KAVITA (DDS)
Entity type:Individual
Prefix:DR
First Name:KAVITA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S YORK RD
Mailing Address - Street 2:SUITE 3110
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5626
Mailing Address - Country:US
Mailing Address - Phone:630-782-6999
Mailing Address - Fax:630-782-6790
Practice Address - Street 1:1200 S YORK RD
Practice Address - Street 2:SUITE 3110
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5626
Practice Address - Country:US
Practice Address - Phone:630-782-6999
Practice Address - Fax:630-782-6790
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190230071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019023007OtherSTATE LICENSE