=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558442202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SQUARE LAKE FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 01/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6053 ROCHESTER RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-879-5858
-----------------------------------------------------
Fax | 248-879-3578
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6053 ROCHESTER RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-879-5858
-----------------------------------------------------
Fax | 248-879-3578
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | DR. PRITIDA TUSHAR PATEL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 248-879-5858
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901015929
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901015961
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------