Healthcare Provider Details

I. General information

NPI: 1396127411
Provider Name (Legal Business Name): MANAN HARSHADRAY PATEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W BALTIMORE ST DEPT OF
BALTIMORE MD
21201-1510
US

IV. Provider business mailing address

650 W BALTIMORE ST DEPARTMENT OF ORAL-MAXILLOFACIAL SURGERY
BALTIMORE MD
21201-1510
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-7101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901021602
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: