Provider Demographics
NPI:1548496490
Name:PATEL, MIT BAKULESH (DDS)
Entity type:Individual
Prefix:DR
First Name:MIT
Middle Name:BAKULESH
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 1:2015 VALLEYGATE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3757
Mailing Address - Country:US
Mailing Address - Phone:910-485-7070
Mailing Address - Fax:910-485-1151
Practice Address - Street 1:2029 VALLEYGATE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3771
Practice Address - Country:US
Practice Address - Phone:910-485-8884
Practice Address - Fax:910-485-8287
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC87731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913155Medicaid