=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437445111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHREENA R. PATEL DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2011
-----------------------------------------------------
Last Update Date | 06/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 775 UNION BLVD
-----------------------------------------------------
City | TOTOWA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07512-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-812-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 775 UNION BLVD
-----------------------------------------------------
City | TOTOWA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07512-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-812-1234
-----------------------------------------------------
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 | 22DI02517400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------