Healthcare Provider Details

I. General information

NPI: 1376682005
Provider Name (Legal Business Name): JEETENDRA PATEL, DDS, A PROFESSIONAL DENTAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 STERLINGTON RD
MONROE LA
71203-2522
US

IV. Provider business mailing address

3340 STERLINGTON RD
MONROE LA
71203-2522
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-2922
  • Fax:
Mailing address:
  • Phone: 318-325-2922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5451
License Number StateLA

VIII. Authorized Official

Name: DR. JEETENDRA S PATEL
Title or Position: OWNER
Credential: DDS
Phone: 318-325-2922