Provider Demographics
NPI:1962387290
Name:PATEL, SHIVAM (DMD)
Entity type:Individual
Prefix:
First Name:SHIVAM
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6878 SESSIONS DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1332
Mailing Address - Country:US
Mailing Address - Phone:415-509-4496
Mailing Address - Fax:
Practice Address - Street 1:4100 PORTOLA DR STE 2
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4500
Practice Address - Country:US
Practice Address - Phone:831-475-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1118411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty