Healthcare Provider Details

I. General information

NPI: 1326630575
Provider Name (Legal Business Name): SAMIDHA PATEL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12420 SAN JOSE BLVD
JACKSONVILLE FL
32223-2643
US

IV. Provider business mailing address

13547 HOLSINGER BLVD
JACKSONVILLE FL
32256-8646
US

V. Phone/Fax

Practice location:
  • Phone: 904-901-4691
  • Fax:
Mailing address:
  • Phone: 956-299-6184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN25664
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: