Provider Demographics
NPI:1629505201
Name:PATEL, SATYAM
Entity Type:Individual
Prefix:
First Name:SATYAM
Middle Name:
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 1:1140 FLAMINGO DR
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-4730
Mailing Address - Country:US
Mailing Address - Phone:630-267-6923
Mailing Address - Fax:
Practice Address - Street 1:845 S PERRYVILLE RD UNIT 127
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4340
Practice Address - Country:US
Practice Address - Phone:630-267-6923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0314381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty