Provider Demographics
NPI:1043864168
Name:PATEL, NIYATI
Entity Type:Individual
Prefix:
First Name:NIYATI
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10622 PARK PLACE DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-3402
Mailing Address - Country:US
Mailing Address - Phone:360-622-5623
Mailing Address - Fax:
Practice Address - Street 1:870 N US HIGHWAY 27 STE A
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3108
Practice Address - Country:US
Practice Address - Phone:360-622-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24458122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist