Provider Demographics
NPI:1831630763
Name:PATEL, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:PATEL
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 1:1821 W CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-2521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11501 S 4000 W STE 101
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009
Practice Address - Country:US
Practice Address - Phone:017-012-1208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10635042-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist