Provider Demographics
NPI:1902819352
Name:PATEL, KETAN (DMD)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 N MAIN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-8376
Mailing Address - Country:US
Mailing Address - Phone:678-762-1613
Mailing Address - Fax:678-762-1689
Practice Address - Street 1:342 N MAIN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-8376
Practice Address - Country:US
Practice Address - Phone:678-762-1613
Practice Address - Fax:678-762-1689
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0128351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA500129458BMedicaid