Healthcare Provider Details

I. General information

NPI: 1720058217
Provider Name (Legal Business Name): JAYESH SURENDRA PATEL B.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 FAIRFAX CORNER WEST AVE SUITE 230
FAIRFAX VA
22030-8619
US

IV. Provider business mailing address

21487 DOWNING CT
ASHBURN VA
20147-5812
US

V. Phone/Fax

Practice location:
  • Phone: 703-361-1136
  • Fax: 703-631-1337
Mailing address:
  • Phone: 703-724-9282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401410150
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: