=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154097434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCEL DENTAL OF EVERETT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2021
-----------------------------------------------------
Last Update Date | 08/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1795 REVERE BEACH PKWY
-----------------------------------------------------
City | EVERETT
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02149-5912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-433-8060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1795 REVERE BEACH PKWY
-----------------------------------------------------
City | EVERETT
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02149-5912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-433-8060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHITRANG B. PATEL
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 617-433-8060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------