Healthcare Provider Details

I. General information

NPI: 1750766499
Provider Name (Legal Business Name): DHAVAL PATEL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 VISA DR
NORMAL IL
61761-2195
US

IV. Provider business mailing address

110 W CENTER ST # NA
OTTAWA IL
61350-3557
US

V. Phone/Fax

Practice location:
  • Phone: 309-585-2522
  • Fax:
Mailing address:
  • Phone: 815-434-6411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.030334
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: