Provider Demographics
NPI:1790047215
Name:LAKE TRAVIS FAMILY & COSMETIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:LAKE TRAVIS FAMILY & COSMETIC DENTISTRY PLLC
Other - Org Name:LAKE TRAVIS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PANAHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-382-6985
Mailing Address - Street 1:1605 RR 620 N
Mailing Address - Street 2:STE 300
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-2695
Mailing Address - Country:US
Mailing Address - Phone:512-382-6985
Mailing Address - Fax:
Practice Address - Street 1:1605 RR 620 N
Practice Address - Street 2:STE 300
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-2695
Practice Address - Country:US
Practice Address - Phone:512-382-6985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty