Healthcare Provider Details

I. General information

NPI: 1689749285
Provider Name (Legal Business Name): PRAVINBHAI K PATEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N EL DORADO ST
STOCKTON CA
95202-1906
US

IV. Provider business mailing address

623 MUIRFIELD TER
FREMONT CA
94536-3279
US

V. Phone/Fax

Practice location:
  • Phone: 209-943-3990
  • Fax:
Mailing address:
  • Phone: 510-796-6791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number49389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: