Healthcare Provider Details

I. General information

NPI: 1407103658
Provider Name (Legal Business Name): NISHANT PATEL D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 W LAWRENCE AVE
CHICAGO IL
60630-2510
US

IV. Provider business mailing address

965 PIMLICO LN
BARTLETT IL
60103-2073
US

V. Phone/Fax

Practice location:
  • Phone: 773-725-6086
  • Fax:
Mailing address:
  • Phone: 630-776-1432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.028279
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021002461
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: