=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215386735
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | POOJA PATEL D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2016
-----------------------------------------------------
Last Update Date | 06/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8430 PERSHALL RD
-----------------------------------------------------
City | HAZELWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63042-3075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-527-0159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3354 BRIDGETON TRAILS DR
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63044-2876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-402-9908
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 2016016884
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------