Provider Demographics
NPI:1285065425
Name:PATEL, SHARDA KETAN
Entity type:Individual
Prefix:
First Name:SHARDA
Middle Name:KETAN
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3036 BLACKBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5413
Mailing Address - Country:US
Mailing Address - Phone:714-924-4338
Mailing Address - Fax:
Practice Address - Street 1:3036 BLACKBERRY AVE
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-5413
Practice Address - Country:US
Practice Address - Phone:714-924-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63503122300000X
CODEN.00202037122300000X
PADS039817122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist