Healthcare Provider Details

I. General information

NPI: 1497598650
Provider Name (Legal Business Name): SHIVANI VASUDEV-PATEL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 LAKE JOY RD
KATHLEEN GA
31047-2113
US

IV. Provider business mailing address

1 KNEELAND ST
BOSTON MA
02111-1527
US

V. Phone/Fax

Practice location:
  • Phone: 478-772-8883
  • Fax:
Mailing address:
  • Phone: 770-337-3508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124267
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: