Provider Demographics
NPI:1891477402
Name:PATEL, DIVYANG P
Entity Type:Individual
Prefix:
First Name:DIVYANG
Middle Name:P
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 1:173 APPIAN WAY
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-3703
Mailing Address - Country:US
Mailing Address - Phone:832-209-0160
Mailing Address - Fax:
Practice Address - Street 1:4053 E MORADA LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-1608
Practice Address - Country:US
Practice Address - Phone:832-209-0160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1090501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice