Provider Demographics
NPI:1093215881
Name:PATEL, PRATIKKUMAR PRAVINBHAI (DDS)
Entity type:Individual
Prefix:
First Name:PRATIKKUMAR
Middle Name:PRAVINBHAI
Last Name:PATEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:PRATIKKUMAR
Other - Middle Name:P
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:3634 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6518
Mailing Address - Country:US
Mailing Address - Phone:706-860-8228
Mailing Address - Fax:
Practice Address - Street 1:3634 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6518
Practice Address - Country:US
Practice Address - Phone:706-860-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-18
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX35841122300000X
GADN1225221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist