Healthcare Provider Details

I. General information

NPI: 1780042010
Provider Name (Legal Business Name): NIRAV VISHNUPRASAD PATEL BDS, MPH, MDS, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2016
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13515 LAKE TERRACE LN
TAMPA FL
33637-1003
US

IV. Provider business mailing address

1131 BAYCREST DR
WESLEY CHAPEL FL
33544-7675
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-2000
  • Fax:
Mailing address:
  • Phone: 347-567-5081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901022100
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19030547
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number31635
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number22DI02784000
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number060848
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN25627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: