MEDICARE: DR. CHETAN SHYAM PATIL DDS

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	1223P0300X	Periodontics	053823	NY
2	1223P0300X	Periodontics	22DI02429400	NJ
3	1223P0300X	Periodontics	D010274	AZ

General Provider Information

NPI Number	:	1548598576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHETAN SHYAM PATIL DDS

Provider Business Mailing Address
First Line	:	5526 N 79TH ST
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85250-6503
Country	:	US
Telephone Number	:	201-468-2692
Fax Number	:

Provider Business Practice Location Address
First Line	:	4025 W BELL RD STE 4
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85053-2748
Country	:	US
Telephone Number	:	480-744-3881
Fax Number	:

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

Provider Enumeration Date	:	12/02/2009
Last Update Date	:	08/03/2023

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