MEDICARE: DR. LISA PATEL D.D.S

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	122300000X	Dentist	14570	MD

General Provider Information

NPI Number	:	1164734752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA PATEL D.D.S

Provider Business Mailing Address
First Line	:	723 WINTON AVE
Second Line	:
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-2479
Country	:	US
Telephone Number	:	410-761-5615
Fax Number	:

Provider Business Practice Location Address
First Line	:	28160 OLD VILLAGE RD
Second Line	:
City	:	MECHANICSVILLE
State	:	MD
Zip	:	20659-4289
Country	:	US
Telephone Number	:	301-884-9594
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2010
Last Update Date	:	07/12/2010

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