=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124113055
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAI VALLABH PATEL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 11/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 SILVERLAKE VILLAGE DR SUITE 100
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-8419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-436-9959
-----------------------------------------------------
Fax | 713-436-9968
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3000 SILVERLAKE VILLAGE DR SUITE 100
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-8419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-436-9959
-----------------------------------------------------
Fax | 713-436-9968
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 20508
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------