Provider Demographics
NPI:1881787158
Name:PATEL, MITA SHARAD (DDS)
Entity type:Individual
Prefix:MRS
First Name:MITA
Middle Name:SHARAD
Last Name:PATEL
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 1:592 ROCKAWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-5539
Mailing Address - Country:US
Mailing Address - Phone:718-345-5000
Mailing Address - Fax:
Practice Address - Street 1:679 E 138TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454
Practice Address - Country:US
Practice Address - Phone:718-665-6065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04064511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01004457Medicaid