Healthcare Provider Details

I. General information

NPI: 1639269764
Provider Name (Legal Business Name): TARAK CHAMPAKLAL PATEL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2262 DUNN AVENUE SUITE 1
JACKSONVILLE FL
32218
US

IV. Provider business mailing address

9969 CHELSEA LAKE RD
JACKSONVILLE FL
32256-3482
US

V. Phone/Fax

Practice location:
  • Phone: 904-757-7940
  • Fax: 904-757-7942
Mailing address:
  • Phone: 904-464-0300
  • Fax: 904-757-7940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN14212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: