Provider Demographics
NPI:1679201115
Name:PATEL, KRUNAL KAUSHIKBHAI (DDS)
Entity type:Individual
Prefix:DR
First Name:KRUNAL
Middle Name:KAUSHIKBHAI
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 1:12168 MOUNT VERNON AVE UNIT 30
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5541
Mailing Address - Country:US
Mailing Address - Phone:201-736-1176
Mailing Address - Fax:
Practice Address - Street 1:2320 E MORELAND BLVD STE A
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2948
Practice Address - Country:US
Practice Address - Phone:262-524-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107748122300000X
WI6001327-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist