Basic Information
| Provider Information | |||||||||
| NPI: | 1114333903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | ROSHAN | ||||||||
| MiddleName: | VIJAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 EDWARDS RANCH RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172922004 | ||||||||
| FaxNumber: | 8172927083 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 EDWARDS RANCH RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172922004 | ||||||||
| FaxNumber: | 8172927083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2014 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0977 | NC | N | Dental Providers | Dentist | 122300000X | 20642 | FL | N | Dental Providers | Dentist | 1223G0001X | 30.025952 | OH | N | Dental Providers | Dentist | General Practice | 1223P0221X | 36187 | TX | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 020110100 | 05 | FL | MEDICAID |