Provider Demographics
NPI:1013907070
Name:PATEL, SURENDRA R (DDS)
Entity Type:Individual
Prefix:DR
First Name:SURENDRA
Middle Name:R
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 1:250 W CLARKSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-7221
Mailing Address - Country:US
Mailing Address - Phone:845-352-4405
Mailing Address - Fax:845-352-4405
Practice Address - Street 1:48 E KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-7514
Practice Address - Country:US
Practice Address - Phone:718-933-9603
Practice Address - Fax:718-866-0337
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033320122300000X, 122300000X
FLDN 0013148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY033320OtherSTATE LICENSE #
NY00291350Medicaid
11-2479388OtherFED. EMP. ID. #
11-2479388OtherFED. EMP. ID. #