Provider Demographics
NPI:1841673951
Name:GUPTA, RAJAN
Entity type:Individual
Prefix:MR
First Name:RAJAN
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9918 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5770
Mailing Address - Country:US
Mailing Address - Phone:260-888-3502
Mailing Address - Fax:260-233-6656
Practice Address - Street 1:9918 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5770
Practice Address - Country:US
Practice Address - Phone:260-888-3502
Practice Address - Fax:260-233-6656
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4363122300000X
IN12013764A1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12013764AOtherDENTAL BOARD