Provider Demographics
NPI:1093215881
Name:PATEL, PRATIKKUMAR PRAVINBHAI (DDS)
Entity Type:Individual
Prefix:
First Name:PRATIKKUMAR
Middle Name:PRAVINBHAI
Last Name:PATEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 TOWNE PARK DR W STE 301
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-5258
Mailing Address - Country:US
Mailing Address - Phone:912-354-1515
Mailing Address - Fax:
Practice Address - Street 1:613 TOWNE PARK DR W STE 301
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5258
Practice Address - Country:US
Practice Address - Phone:912-295-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-18
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35841122300000X
390200000X
GADN1225221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program