MEDICARE: NISHA M PATEL, DDS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	44431	CA

General Provider Information

NPI Number	:	1053856757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NISHA M PATEL, DDS INC

Provider Business Mailing Address
First Line	:	905 S LAKE ST
Second Line	:	# 102
City	:	BURBANK
State	:	CA
Zip	:	91502-2436
Country	:	US
Telephone Number	:	818-843-6411
Fax Number	:	818-843-6416

Provider Business Practice Location Address
First Line	:	905 S LAKE ST
Second Line	:	# 102
City	:	BURBANK
State	:	CA
Zip	:	91502-2436
Country	:	US
Telephone Number	:	818-843-6411
Fax Number	:	818-843-6416

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. NISHA M PATEL
Credential	:	DDS
Telephone Number	:	818-843-6411

Provider Enumeration Date	:	01/04/2017
Last Update Date	:	01/04/2017

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