Provider Demographics
NPI:1417693706
Name:PATEL, PRUTHA (DMD)
Entity Type:Individual
Prefix:
First Name:PRUTHA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 STARWOOD LN UNIT 25
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6636
Mailing Address - Country:US
Mailing Address - Phone:484-506-4816
Mailing Address - Fax:
Practice Address - Street 1:6111 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-5714
Practice Address - Country:US
Practice Address - Phone:517-393-3447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601453122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist