Basic Information
| Provider Information | |||||||||
| NPI: | 1881787158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | MITA | ||||||||
| MiddleName: | SHARAD | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 592 ROCKAWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112125539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183455000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 679 E 138TH ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186656065 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2006 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0406451 | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 01004457 | 05 | NY | MEDICAID |