Healthcare Provider Details

I. General information

NPI: 1225233679
Provider Name (Legal Business Name): KETAN PATEL DDS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2007
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 OAKDALE AVE N NORTH MEMORIAL MEDICAL CENTER
MINNEAPOLIS MN
55422
US

IV. Provider business mailing address

3366 OAKDALE AVE N SUITE 200
MINNEAPOLIS MN
55422
US

V. Phone/Fax

Practice location:
  • Phone: 763-581-5360
  • Fax: 763-581-5361
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS95
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: