Provider Demographics
NPI:1902117203
Name:PATEL, KOMAL S (DDS)
Entity type:Individual
Prefix:
First Name:KOMAL
Middle Name:S
Last Name:PATEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2281 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7365
Mailing Address - Country:US
Mailing Address - Phone:919-306-2870
Mailing Address - Fax:
Practice Address - Street 1:28345 BECK RD
Practice Address - Street 2:#409
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-4733
Practice Address - Country:US
Practice Address - Phone:888-477-7325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901021723122300000X
NY055639122300000X
NJDI02502600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program