Provider Demographics
NPI:1811097389
Name:PATEL, SURESH (DMD)
Entity type:Individual
Prefix:DR
First Name:SURESH
Middle Name:
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 1:375 EAST MAIN STREET
Mailing Address - Street 2:SUITE 19
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-665-0165
Mailing Address - Fax:631-665-0050
Practice Address - Street 1:375 EAST MAIN STREET
Practice Address - Street 2:SUITE 19
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-665-0165
Practice Address - Fax:631-665-0050
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0490351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113603733OtherTAX ID NUMBER