Provider Demographics
NPI:1578857561
Name:PATEL, RUPAL (DMD)
Entity Type:Individual
Prefix:
First Name:RUPAL
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 1:1804 WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2806
Mailing Address - Country:US
Mailing Address - Phone:309-287-3186
Mailing Address - Fax:
Practice Address - Street 1:1804 WOODBINE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2806
Practice Address - Country:US
Practice Address - Phone:309-287-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2012-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27982122300000X
IL019.0287991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice