Provider Demographics
NPI:1164861324
Name:PATEL, RAVI KUMAR VIJAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAVI KUMAR
Middle Name:VIJAY
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:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-3251
Practice Address - Street 1:6091 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2619
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-764-5356
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012016A122300000X
IL019029457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist