Healthcare Provider Details

I. General information

NPI: 1114333903
Provider Name (Legal Business Name): ROSHAN VIJAY PATEL D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 EDWARDS RANCH RD STE 100
FORT WORTH TX
76109-4128
US

IV. Provider business mailing address

5700 EDWARDS RANCH RD STE 100
FORT WORTH TX
76109-4128
US

V. Phone/Fax

Practice location:
  • Phone: 817-292-2004
  • Fax: 817-292-7083
Mailing address:
  • Phone: 817-292-2004
  • Fax: 817-292-7083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0977
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number20642
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.025952
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number36187
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: