Provider Demographics
NPI:1437867611
Name:PATEL, SHIVAM DIPAK (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHIVAM
Middle Name:DIPAK
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 1:1110 FORT WORTH HWY
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-4528
Mailing Address - Country:US
Mailing Address - Phone:817-629-9734
Mailing Address - Fax:
Practice Address - Street 1:2240 MARKET PLACE BLVD STE 140
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-8098
Practice Address - Country:US
Practice Address - Phone:817-629-9734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX391221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice