Healthcare Provider Details

I. General information

NPI: 1790248524
Provider Name (Legal Business Name): DYLAN RACHA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 VETERANS MEMORIAL BLVD STE 203
METAIRIE LA
70002-8440
US

IV. Provider business mailing address

6841 GLASS FACTORY RD
HOLLAND PATENT NY
13354-4135
US

V. Phone/Fax

Practice location:
  • Phone: 504-887-6453
  • Fax:
Mailing address:
  • Phone: 315-794-8576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7292
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: