MEDICARE: YAGNIK PATEL

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	1223G0001X	General Practice Dentistry	019031506	IL
2	1223E0200X	Endodontics	31926	TX

General Provider Information

NPI Number	:	1164873204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YAGNIK PATEL

Provider Business Mailing Address
First Line	:	3821 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-3355
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3821 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-3355
Country	:	US
Telephone Number	:	609-202-8123
Fax Number	:

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

Provider Enumeration Date	:	06/30/2016
Last Update Date	:	07/21/2020

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Directions to “ YAGNIK PATEL ” Practice Location

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