Provider Demographics
NPI:1770573594
Name:DESAI, MITA (DDS)
Entity type:Individual
Prefix:DR
First Name:MITA
Middle Name:
Last Name:DESAI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4763 BARWICK DR STE 106
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-1531
Mailing Address - Country:US
Mailing Address - Phone:817-926-5485
Mailing Address - Fax:817-924-0014
Practice Address - Street 1:4763 BARWICK DR STE 106
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-1531
Practice Address - Country:US
Practice Address - Phone:817-926-5485
Practice Address - Fax:817-924-0014
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21968122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist