Healthcare Provider Details

I. General information

NPI: 1942048707
Provider Name (Legal Business Name): RAJ PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 ROSCOMMON DR
ORMOND BEACH FL
32174-2850
US

IV. Provider business mailing address

136 JOYELLE CIR
DAYTONA BEACH FL
32124-2034
US

V. Phone/Fax

Practice location:
  • Phone: 386-559-6068
  • Fax:
Mailing address:
  • Phone: 908-397-1654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDL100440
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN29449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: