=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740308576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 11/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 342 N MAIN ST SUITE 110
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30004-8376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-762-1613
-----------------------------------------------------
Fax | 678-762-1689
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 342 N MAIN ST SUITE 110
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30004-8376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-762-1613
-----------------------------------------------------
Fax | 678-762-1689
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. KETANKUMAR G PATEL
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 678-762-1613
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN008017
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN007359
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN012835
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------