Healthcare Provider Details

I. General information

NPI: 1578296570
Provider Name (Legal Business Name): KETU PATEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 W BANKHEAD HWY
VILLA RICA GA
30180-1702
US

IV. Provider business mailing address

127 AFFINITY LN APT C
BUFFALO NY
14215-2446
US

V. Phone/Fax

Practice location:
  • Phone: 770-456-2550
  • Fax:
Mailing address:
  • Phone: 224-388-1497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN122752
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: