Healthcare Provider Details

I. General information

NPI: 1790804920
Provider Name (Legal Business Name): SAMIR PATEL DDS ,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 BELLEVILLE AVE
BLOOMFIELD NJ
07003-3652
US

IV. Provider business mailing address

332 BELLEVILLE AVE
BLOOMFIELD NJ
07003-3652
US

V. Phone/Fax

Practice location:
  • Phone: 973-743-1755
  • Fax: 973-743-6199
Mailing address:
  • Phone: 973-743-1755
  • Fax: 973-743-6199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20649
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SAMIR P PATEL
Title or Position: SOLE MEMBER
Credential: D.D.S.
Phone: 973-743-1755