MEDICARE: DR. SUSHMA C LAVU DDS

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	24206	TX

General Provider Information

NPI Number	:	1629216551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSHMA C LAVU DDS

Provider Business Mailing Address
First Line	:	3021 ROLLING WOOD LN
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-0365
Country	:	US
Telephone Number	:	817-788-0776
Fax Number	:

Provider Business Practice Location Address
First Line	:	6924 SOUTH FWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-3800
Country	:	US
Telephone Number	:	817-293-7431
Fax Number	:	817-293-3848

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

Provider Enumeration Date	:	01/30/2009
Last Update Date	:	05/25/2011

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