Provider Demographics
NPI:1023387800
Name:LANESE FAMILY DENTAL,PA
Entity Type:Organization
Organization Name:LANESE FAMILY DENTAL,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-684-5040
Mailing Address - Street 1:6502 BANDERA RD
Mailing Address - Street 2:STE 201
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1400
Mailing Address - Country:US
Mailing Address - Phone:210-684-5040
Mailing Address - Fax:210-682-7785
Practice Address - Street 1:6502 BANDERA RD
Practice Address - Street 2:STE 201
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1400
Practice Address - Country:US
Practice Address - Phone:210-684-5040
Practice Address - Fax:210-682-7785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX180631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11189001Medicaid