=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851725899
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | UTTAMKUMAR R PATEL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2013
-----------------------------------------------------
Last Update Date | 08/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4312 E LINCOLNWAY SUITE A
-----------------------------------------------------
City | STERLING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61081-9793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-625-7002
-----------------------------------------------------
Fax | 815-625-7848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 603 APPLE ST
-----------------------------------------------------
City | DIXON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61021-1102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-565-4437
-----------------------------------------------------
Fax | 815-625-7848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.029619
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------