Provider Demographics
NPI:1336339779
Name:PATEL, VIPUL ANANT (DMD)
Entity Type:Individual
Prefix:DR
First Name:VIPUL
Middle Name:ANANT
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 1:553 PORTLAND COBALT RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1968
Mailing Address - Country:US
Mailing Address - Phone:860-751-9195
Mailing Address - Fax:
Practice Address - Street 1:553 PORTLAND COBALT RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:CT
Practice Address - Zip Code:06480-1968
Practice Address - Country:US
Practice Address - Phone:860-751-9195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0097851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02813156Medicaid
CT009-785OtherCT DENTAL LICENCE NUMBER
CT908002145Medicaid