Provider Demographics
NPI:1669450649
Name:PROCTER, NIRALI PATEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:NIRALI
Middle Name:PATEL
Last Name:PROCTER
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 1:205 WALESKA RD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2493
Mailing Address - Country:US
Mailing Address - Phone:770-479-1717
Mailing Address - Fax:
Practice Address - Street 1:205 WALESKA RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2493
Practice Address - Country:US
Practice Address - Phone:770-479-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4088Medicaid