Provider Demographics
NPI:1477818391
Name:PATEL, JIMISHKUMAR GHANSHYAMBHAI
Entity Type:Individual
Prefix:
First Name:JIMISHKUMAR
Middle Name:GHANSHYAMBHAI
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 1:35 NORTHAMPTON ST APT 1801
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4019
Mailing Address - Country:US
Mailing Address - Phone:857-234-6289
Mailing Address - Fax:
Practice Address - Street 1:100 E NEWTON ST
Practice Address - Street 2:AEGD DEPARTMENT
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL11604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist