Healthcare Provider Details

I. General information

NPI: 1407985526
Provider Name (Legal Business Name): SUKETU PATEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MAIN ST
BUFFALO NY
14209-2308
US

IV. Provider business mailing address

1100 MAIN ST
BUFFALO NY
14209-2308
US

V. Phone/Fax

Practice location:
  • Phone: 716-242-8200
  • Fax:
Mailing address:
  • Phone: 716-242-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number051327
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: