MEDICARE: ALBATROSS 46 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1255961843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBATROSS 46 LLC

Provider Business Mailing Address
First Line	:	4231 SIGMA RD STE 100
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75244-4471
Country	:	US
Telephone Number	:	972-233-5447
Fax Number	:

Provider Business Practice Location Address
First Line	:	4231 SIGMA RD STE 100
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75244-4471
Country	:	US
Telephone Number	:	972-233-5447
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RASHID BEIRUTE-PRADA
Credential	:	DDS, MDS
Telephone Number	:	817-229-0930

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	01/22/2020

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