Provider Demographics
NPI:1962194639
Name:PATEL, JAY BHAGAVANDAS (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:BHAGAVANDAS
Last Name:PATEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 DOUTHART PL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-9188
Mailing Address - Country:US
Mailing Address - Phone:517-402-9557
Mailing Address - Fax:
Practice Address - Street 1:1005 E LASALLE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2818
Practice Address - Country:US
Practice Address - Phone:574-367-7146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014074A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist