MEDICARE: WATERFRONT FAMILY DENTISTRY PLLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1760072193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERFRONT FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	255 W LEBANON STE 300
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75036-3415
Country	:	US
Telephone Number	:	972-987-4343
Fax Number	:	972-987-4346

Provider Business Practice Location Address
First Line	:	255 W LEBANON STE 300
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75036-3415
Country	:	US
Telephone Number	:	972-987-4343
Fax Number	:	972-987-4346

Authorized Official
Title or Position	:	OWNER
Name	:	LAVANYA RUDRAPATNA
Credential	:	DMD
Telephone Number	:	214-563-5333

Provider Enumeration Date	:	01/20/2021
Last Update Date	:	10/19/2023

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