Provider Demographics
NPI:1114333903
Name:PATEL, ROSHAN VIJAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROSHAN
Middle Name:VIJAY
Last Name:PATEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 EDWARDS RANCH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4128
Mailing Address - Country:US
Mailing Address - Phone:817-292-2004
Mailing Address - Fax:817-292-7083
Practice Address - Street 1:5700 EDWARDS RANCH RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4128
Practice Address - Country:US
Practice Address - Phone:817-292-2004
Practice Address - Fax:817-292-7083
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0977122300000X
FL20642122300000X
OH30.0259521223G0001X
TX361871223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020110100Medicaid