MEDICARE: AMIEL R. PATEL, D.D.S; PROF. DENTAL CORP.

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	42210	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B42210-01	OTHER	CA	DENTICAL

General Provider Information

NPI Number	:	1538420575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMIEL R. PATEL, D.D.S; PROF. DENTAL CORP.

Provider Business Mailing Address
First Line	:	4921 MORENO ST
Second Line	:
City	:	MONTCLAIR
State	:	CA
Zip	:	91763-1522
Country	:	US
Telephone Number	:	909-625-3865
Fax Number	:

Provider Business Practice Location Address
First Line	:	4921 MORENO ST
Second Line	:
City	:	MONTCLAIR
State	:	CA
Zip	:	91763-1522
Country	:	US
Telephone Number	:	909-625-3865
Fax Number	:

Authorized Official
Title or Position	:	OWNER, PRESIDENT
Name	:	DR. AMIEL RAJESH PATEL
Credential	:	DDS
Telephone Number	:	909-625-3865

Provider Enumeration Date	:	06/06/2012
Last Update Date	:	04/09/2015

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