Healthcare Provider Details

I. General information

NPI: 1407417025
Provider Name (Legal Business Name): GOPALI PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date: 06/25/2019
Reactivation Date: 07/31/2019

III. Provider practice location address

117 SPRATT ST STE A
FORT MILL SC
29715-4111
US

IV. Provider business mailing address

117 SPRATT ST STE A
FORT MILL SC
29715-4111
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-2191
  • Fax:
Mailing address:
  • Phone: 803-548-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9407
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: