MEDICARE: LAITH FAMILY DENTISTRY CENTRAL

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	25079	TX

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	:	1811411937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAITH FAMILY DENTISTRY CENTRAL

Provider Business Mailing Address
First Line	:	PO BOX 1735
Second Line	:
City	:	HELOTES
State	:	TX
Zip	:	78023-1735
Country	:	US
Telephone Number	:	210-782-0008
Fax Number	:

Provider Business Practice Location Address
First Line	:	3131 NACOGDOCHES RD STE 103
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-3335
Country	:	US
Telephone Number	:	210-782-0008
Fax Number	:

Authorized Official
Title or Position	:	DDS/OWNER
Name	:	DR. RACHA KADAMANI
Credential	:
Telephone Number	:	210-782-0008

Provider Enumeration Date	:	07/31/2017
Last Update Date	:	07/31/2017

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