Provider Demographics
NPI:1639191463
Name:PATEL, SUBHASHCHANDRA AMBALAL (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUBHASHCHANDRA
Middle Name:AMBALAL
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 1:2716 UPPER AFTON ROAD E.
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-0449
Mailing Address - Country:US
Mailing Address - Phone:651-739-5110
Mailing Address - Fax:651-739-1873
Practice Address - Street 1:2716 UPPER AFTON ROAD E.
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-0449
Practice Address - Country:US
Practice Address - Phone:651-739-5110
Practice Address - Fax:651-739-1873
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8395122300000X
MND83951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN983217300Medicaid