MEDICARE: DR. KEITH PATEL D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019030455	IL

General Provider Information

NPI Number	:	1194191965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH PATEL D.M.D.

Provider Business Mailing Address
First Line	:	2756 W CERMAK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3528
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2756 W CERMAK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3528
Country	:	US
Telephone Number	:	773-247-5707
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2015
Last Update Date	:	03/23/2016

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