=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205721305
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATEL DENTAL WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2025
-----------------------------------------------------
Last Update Date | 06/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10360 W FOREST HOME AVE
-----------------------------------------------------
City | HALES CORNERS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53130-2132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-425-0505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11544 W MEADOWVIEW DR
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53132-2412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-704-2361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. AMIT PATEL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 847-704-2361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------