Healthcare Provider Details

I. General information

NPI: 1306164066
Provider Name (Legal Business Name): PREM PATEL DMD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 W INTERSTATE 20 STE 300
ARLINGTON TX
76017
US

IV. Provider business mailing address

2805 BAZE RD
EULESS TX
76039-7859
US

V. Phone/Fax

Practice location:
  • Phone: 214-317-4039
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number37153
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number021.002766
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036.141884
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberT1511
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: