Provider Demographics
NPI:1770868978
Name:DESAI, HETAL P
Entity type:Individual
Prefix:
First Name:HETAL
Middle Name:P
Last Name:DESAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930A W SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-3511
Mailing Address - Country:US
Mailing Address - Phone:918-682-2819
Mailing Address - Fax:
Practice Address - Street 1:930A W SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-3511
Practice Address - Country:US
Practice Address - Phone:918-682-2819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64171223G0001X
TX27496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist