Healthcare Provider Details

I. General information

NPI: 1891677712
Provider Name (Legal Business Name): SEJAL T PATEL
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W STATE ST
ROCKFORD IL
61102-2112
US

IV. Provider business mailing address

1200 W STATE ST
ROCKFORD IL
61102-2112
US

V. Phone/Fax

Practice location:
  • Phone: 815-490-1600
  • Fax: 815-490-1881
Mailing address:
  • Phone: 815-490-1600
  • Fax: 815-490-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.036242
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: