Provider Demographics
NPI:1144658360
Name:GUPTA, SHAILY (DDS)
Entity type:Individual
Prefix:
First Name:SHAILY
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 1:1000 N MIDKIFF RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701
Mailing Address - Country:US
Mailing Address - Phone:407-353-5043
Mailing Address - Fax:
Practice Address - Street 1:1000 N MIDKIFF RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-2101
Practice Address - Country:US
Practice Address - Phone:432-897-0852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20468122300000X
MI29010211111223G0001X
TX333661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist