Provider Demographics
NPI:1700560042
Name:PATEL, MITAVA PRAJAY (DMD)
Entity type:Individual
Prefix:
First Name:MITAVA
Middle Name:PRAJAY
Last Name:PATEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4124 RIVER PARK DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3357
Mailing Address - Country:US
Mailing Address - Phone:717-856-3460
Mailing Address - Fax:
Practice Address - Street 1:4124 RIVER PARK DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3357
Practice Address - Country:US
Practice Address - Phone:717-856-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014185021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice