Provider Demographics
NPI:1326185349
Name:PATEL, SUKETU J (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:SUKETU
Middle Name:J
Last Name:PATEL
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 E GRADY ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5104
Mailing Address - Country:US
Mailing Address - Phone:912-665-8657
Mailing Address - Fax:912-764-9789
Practice Address - Street 1:613 E GRADY ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5104
Practice Address - Country:US
Practice Address - Phone:912-665-8657
Practice Address - Fax:912-764-9789
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2014-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0145051223S0112X
NJDI 024722001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003132390BMedicaid