Provider Demographics
NPI:1922326271
Name:PATEL, MITALKUMAR K (DDS)
Entity Type:Individual
Prefix:
First Name:MITALKUMAR
Middle Name:K
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 1:15713 SUS HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906
Mailing Address - Country:US
Mailing Address - Phone:517-505-2939
Mailing Address - Fax:517-484-4439
Practice Address - Street 1:1363 W. LANE ROAD
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115
Practice Address - Country:US
Practice Address - Phone:517-505-2939
Practice Address - Fax:517-484-4439
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist