Healthcare Provider Details

I. General information

NPI: 1114403300
Provider Name (Legal Business Name): NISARG PATEL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 N TUSTIN ST
ORANGE CA
92867-7716
US

IV. Provider business mailing address

179 N TUSTIN ST
ORANGE CA
92867-7716
US

V. Phone/Fax

Practice location:
  • Phone: 714-288-1035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDDS104051
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: