Provider Demographics
NPI:1154468528
Name:THALJI, LARA A (BDS)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:A
Last Name:THALJI
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 E DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7647
Mailing Address - Country:US
Mailing Address - Phone:352-728-8300
Mailing Address - Fax:352-728-8400
Practice Address - Street 1:918 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7647
Practice Address - Country:US
Practice Address - Phone:352-728-8300
Practice Address - Fax:352-728-8400
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL168931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice