MEDICARE: DR. NISHA MAYUR PATEL DDS

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	1223G0001X	General Practice Dentistry	44431	CA

General Provider Information

NPI Number	:	1417970591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NISHA MAYUR PATEL DDS

Provider Business Mailing Address
First Line	:	905 S LAKE ST STE 102
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91502-2436
Country	:	US
Telephone Number	:	818-843-6411
Fax Number	:	818-843-6416

Provider Business Practice Location Address
First Line	:	905 S LAKE ST STE 102
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91502-2436
Country	:	US
Telephone Number	:	818-843-6411
Fax Number	:	818-843-6416

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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