Healthcare Provider Details

I. General information

NPI: 1548382344
Provider Name (Legal Business Name): NIYATI PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 US HIGHWAY 17 SUITE 4
ORANGE PARK FL
32003-8231
US

IV. Provider business mailing address

2502 N ROCKY POINT DR SUITE 1000 - CREDENTIALING
TAMPA FL
33607-1421
US

V. Phone/Fax

Practice location:
  • Phone: 904-215-7855
  • Fax:
Mailing address:
  • Phone: 813-288-1999
  • Fax: 813-289-7549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN16624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: