Provider Demographics
NPI:1104496470
Name:PATEL, KOSTELIC & ASSOCIATES, PLLC
Entity type:Organization
Organization Name:PATEL, KOSTELIC & ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAJIV
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:704-796-7397
Mailing Address - Street 1:2441 MOSS GROVE XING
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6422
Mailing Address - Country:US
Mailing Address - Phone:336-577-1583
Mailing Address - Fax:
Practice Address - Street 1:901 N WINSTEAD AVE STE 120
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8712
Practice Address - Country:US
Practice Address - Phone:704-796-7397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty