Provider Demographics
NPI:1518237189
Name:LAITH FAMILY DENTRISTRY
Entity Type:Organization
Organization Name:LAITH FAMILY DENTRISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHA
Authorized Official - Middle Name:W
Authorized Official - Last Name:KHIREIWISH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-782-6842
Mailing Address - Street 1:10865 SHAENFIELD RD
Mailing Address - Street 2:SUITE 1108
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-9601
Mailing Address - Country:US
Mailing Address - Phone:210-782-6842
Mailing Address - Fax:210-310-3475
Practice Address - Street 1:10865 SHAENFIELD RD
Practice Address - Street 2:SUITE 1108
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-9601
Practice Address - Country:US
Practice Address - Phone:210-782-6842
Practice Address - Fax:210-310-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX250791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid