MEDICARE: ORBIT DENTAL PROFESSIONAL LIMITED LIABILITY COMPANY

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	122300000X	Dentist	25821	TX

General Provider Information

NPI Number	:	1437609302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORBIT DENTAL PROFESSIONAL LIMITED LIABILITY COMPANY

Provider Business Mailing Address
First Line	:	6904 TABERNACLE DRIVE
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7430 N BEACH ST
Second Line	:	SUITE 312
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1541
Country	:	US
Telephone Number	:	732-688-5939
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	ARCHANA M LANKUPALLI
Credential	:	DDS
Telephone Number	:	732-688-5939

Provider Enumeration Date	:	10/04/2016
Last Update Date	:	10/10/2016

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