Healthcare Provider Details

I. General information

NPI: 1326185349
Provider Name (Legal Business Name): SUKETU J. PATEL DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 BRAMPTON AVE
STATESBORO GA
30458-0849
US

IV. Provider business mailing address

1222 BRAMPTON AVE
STATESBORO GA
30458-0849
US

V. Phone/Fax

Practice location:
  • Phone: 912-665-8657
  • Fax: 912-764-9789
Mailing address:
  • Phone: 912-665-8657
  • Fax: 912-764-9789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN014505
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: