MEDICARE: DR. SONAL JITENDRA PATEL MARU DMD

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	10523	CT
2	122300000X	Dentist	010523	CT

General Provider Information

NPI Number	:	1487013355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SONAL JITENDRA PATEL MARU DMD

Provider Business Mailing Address
First Line	:	209 PAXTON WAY
Second Line	:
City	:	GLASTONBURY
State	:	CT
Zip	:	06033-3387
Country	:	US
Telephone Number	:	516-458-9119
Fax Number	:

Provider Business Practice Location Address
First Line	:	277 NEW LONDON TPKE
Second Line	:
City	:	GLASTONBURY
State	:	CT
Zip	:	06033-2232
Country	:	US
Telephone Number	:	860-430-9889
Fax Number	:

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

Provider Enumeration Date	:	02/19/2016
Last Update Date	:	11/02/2017

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