MEDICARE: HETAL P DESAI

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	6417	OK
2	122300000X	Dentist	27496	TX

General Provider Information

NPI Number	:	1770868978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HETAL P DESAI

Provider Business Mailing Address
First Line	:	930A W SHAWNEE ST
Second Line	:
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-3511
Country	:	US
Telephone Number	:	918-682-2819
Fax Number	:

Provider Business Practice Location Address
First Line	:	930A W SHAWNEE ST
Second Line	:
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-3511
Country	:	US
Telephone Number	:	918-682-2819
Fax Number	:

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

Provider Enumeration Date	:	10/19/2011
Last Update Date	:	01/16/2014

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Directions to “ HETAL P DESAI ” Practice Location

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