Healthcare Provider Details

I. General information

NPI: 1356443584
Provider Name (Legal Business Name): SHREENA B. PATEL D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 03/07/2023
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 PROFESSIONAL DR STE 100
PONTE VEDRA BEACH FL
32082-7232
US

IV. Provider business mailing address

150 PROFESSIONAL DR STE 100
PONTE VEDRA BEACH FL
32082-7232
US

V. Phone/Fax

Practice location:
  • Phone: 904-241-2471
  • Fax: 904-241-5673
Mailing address:
  • Phone: 904-241-2471
  • Fax: 904-241-5673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 17187
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN17187
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: