Provider Demographics
NPI:1407103658
Name:PATEL, NISHANT (DDS)
Entity Type:Individual
Prefix:
First Name:NISHANT
Middle Name:
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 1:965 PIMLICO LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-2073
Mailing Address - Country:US
Mailing Address - Phone:630-776-1432
Mailing Address - Fax:
Practice Address - Street 1:4401 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2510
Practice Address - Country:US
Practice Address - Phone:773-725-6086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210024611223X0400X
IL019.028279122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist