Healthcare Provider Details

I. General information

NPI: 1609128818
Provider Name (Legal Business Name): SUKET PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 INDIAN TRAIL RD
NORCROSS GA
30093-4502
US

IV. Provider business mailing address

1235 INDIAN TRAIL RD
NORCROSS GA
30093-4502
US

V. Phone/Fax

Practice location:
  • Phone: 770-931-1333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN012835
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN012835
License Number StateGA

VIII. Authorized Official

Name: DR. KETANKUMAR G PATEL
Title or Position: DENTIST
Credential: DMD
Phone: 770-931-1333