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General NPI Number Information
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NPI Number | 1407103658
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Entity Type | Individual
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Provider Name | NISHANT PATEL D.D.S
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Gender | Male
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Dates
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Enumeration Date | 08/07/2012
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Last Update Date | 08/09/2012
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Provider Practice Location Address
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Address Line | 4401 W LAWRENCE AVE
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City | CHICAGO
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State | IL
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Zip | 60630-2510
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Country | US
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Telephone | 773-725-6086
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Fax |
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Provider Business Mailing Address
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Address Line | 965 PIMLICO LN
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City | BARTLETT
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State | IL
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Zip | 60103-2073
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Country | US
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Telephone | 630-776-1432
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 021002461
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.028279
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License Number State | IL
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