Provider Demographics
NPI:1790178770
Name:PATEL, DHARA (DMD)
Entity Type:Individual
Prefix:DR
First Name:DHARA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:DHARA
Other - Middle Name:PATEL
Other - Last Name:KANSAGRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13 FAR KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE STATION
Mailing Address - State:NJ
Mailing Address - Zip Code:08889-3422
Mailing Address - Country:US
Mailing Address - Phone:610-506-5125
Mailing Address - Fax:609-252-9007
Practice Address - Street 1:626 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-9399
Practice Address - Country:US
Practice Address - Phone:908-688-1039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-14
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ026330122300000X
390200000X
NJ22DI026330001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0526070Medicaid