Healthcare Provider Details

I. General information

NPI: 1235360595
Provider Name (Legal Business Name): REINALDO LASANTA-GARCIA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3622 SHANNON RD STE 101
DURHAM NC
27707-3771
US

IV. Provider business mailing address

3622 SHANNON RD STE 101
DURHAM NC
27707-3771
US

V. Phone/Fax

Practice location:
  • Phone: 919-493-1402
  • Fax: 919-403-2392
Mailing address:
  • Phone: 919-493-1402
  • Fax: 919-403-2392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number018001733
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.028164
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN22426
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9082
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: