MEDICARE: LA FRONTERA DENTAL PLLC

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	1223G0001X	General Practice Dentistry	27257	TX

General Provider Information

NPI Number	:	1790127538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA FRONTERA DENTAL PLLC

Provider Business Mailing Address
First Line	:	2711 LA FRONTERA BLVD
Second Line	:	SUITE 270
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-8005
Country	:	US
Telephone Number	:	512-358-1215
Fax Number	:	512-358-1266

Provider Business Practice Location Address
First Line	:	2711 LA FRONTERA BLVD
Second Line	:	SUITE 270
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-8005
Country	:	US
Telephone Number	:	512-358-1215
Fax Number	:	512-358-1266

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SATYANARAYANAN T THIRUMALAI
Credential	:	DMD
Telephone Number	:	512-358-1215

Provider Enumeration Date	:	07/22/2013
Last Update Date	:	07/22/2013

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