Provider Demographics
NPI:1104279538
Name:PATEL, SHIVAM (DMD)
Entity type:Individual
Prefix:DR
First Name:SHIVAM
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 1:5415 MAPLE AVE
Mailing Address - Street 2:APT 282
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7405
Mailing Address - Country:US
Mailing Address - Phone:978-413-8965
Mailing Address - Fax:
Practice Address - Street 1:2823 KENDALE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-4736
Practice Address - Country:US
Practice Address - Phone:214-350-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31973122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist