Healthcare Provider Details

I. General information

NPI: 1821112723
Provider Name (Legal Business Name): SUKETU I PATEL M.D,, D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2007
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 FREDERICK ST
CUMBERLAND MD
21502-1037
US

IV. Provider business mailing address

1715 FREDERICK ST
CUMBERLAND MD
21502-1037
US

V. Phone/Fax

Practice location:
  • Phone: 301-722-3205
  • Fax: 301-722-3207
Mailing address:
  • Phone: 301-722-3205
  • Fax: 301-722-3207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401411283
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0101238043
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13683
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: