Healthcare Provider Details

I. General information

NPI: 1093215881
Provider Name (Legal Business Name): PRATIKKUMAR PRAVINBHAI PATEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PRATIKKUMAR P PATEL DDS

II. Dates (important events)

Enumeration Date: 02/18/2018
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3634 WHEELER RD
AUGUSTA GA
30909-6518
US

IV. Provider business mailing address

3634 WHEELER RD
AUGUSTA GA
30909-6518
US

V. Phone/Fax

Practice location:
  • Phone: 706-860-8228
  • Fax:
Mailing address:
  • Phone: 706-860-8228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number35841
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN122522
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: