Provider Demographics
NPI:1336679695
Name:PATEL, RAHUL
Entity Type:Individual
Prefix:
First Name:RAHUL
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 SE 39TH CIR
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34480-4952
Mailing Address - Country:US
Mailing Address - Phone:352-239-2177
Mailing Address - Fax:
Practice Address - Street 1:3204 N MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76106-5900
Practice Address - Country:US
Practice Address - Phone:817-380-5574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX330101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty