1518237189 NPI number — LAITH FAMILY DENTRISTRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518237189 NPI number — LAITH FAMILY DENTRISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAITH FAMILY DENTRISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518237189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10865 SHAENFIELD RD
Provider Second Line Business Mailing Address:
SUITE 1108
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78254-9601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-782-6842
Provider Business Mailing Address Fax Number:
210-310-3475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10865 SHAENFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 1108
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78254-9601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-782-6842
Provider Business Practice Location Address Fax Number:
210-310-3475
Provider Enumeration Date:
01/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KHIREIWISH
Authorized Official First Name:
RACHA
Authorized Official Middle Name:
W
Authorized Official Title or Position:
GENERAL DENTIST/OWNER
Authorized Official Telephone Number:
210-782-6842

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  25079 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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