Provider Demographics
NPI:1215628508
Name:PATEL, ROSHAN (DMD)
Entity type:Individual
Prefix:
First Name:ROSHAN
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 1:300 ASHLAND PL APT 25A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-4094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 MARTIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1057
Practice Address - Country:US
Practice Address - Phone:814-366-7858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN10000194122300000X
NY064109122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist