MEDICARE: DR. LAKSHMI J IMMADI D.M.D

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	DN19638	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083988901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAKSHMI J IMMADI D.M.D

Provider Business Mailing Address
First Line	:	10274 POST HARVEST DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33578-3656
Country	:	US
Telephone Number	:	205-807-9311
Fax Number	:

Provider Business Practice Location Address
First Line	:	5101 E BUSCH BLVD
Second Line	:	SUITE 13
City	:	TAMPA
State	:	FL
Zip	:	33617-5380
Country	:	US
Telephone Number	:	205-807-9311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2012
Last Update Date	:	12/31/2015

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