Healthcare Provider Details

I. General information

NPI: 1063772416
Provider Name (Legal Business Name): KAVITA V PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2012
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 W DIVISION ST APT 302
CHICAGO IL
60622-3909
US

IV. Provider business mailing address

525 E MARKET ST
AKRON OH
44304-1619
US

V. Phone/Fax

Practice location:
  • Phone: 937-670-0137
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number319.021385
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: