Healthcare Provider Details

I. General information

NPI: 1104501766
Provider Name (Legal Business Name): DHARA PATEL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 07/12/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 MAIN ST SW D
LOS LUNAS NM
87031
US

IV. Provider business mailing address

1620 MAIN ST SW D
LOS LUNAS NM
87031
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-0651
  • Fax:
Mailing address:
  • Phone: 505-565-0651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDB-2023-0142
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: