Provider Demographics
NPI:1790248524
Name:RACHA, DYLAN (DDS)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:RACHA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6841 GLASS FACTORY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND PATENT
Mailing Address - State:NY
Mailing Address - Zip Code:13354-4135
Mailing Address - Country:US
Mailing Address - Phone:315-794-8576
Mailing Address - Fax:
Practice Address - Street 1:3301 VETERANS MEMORIAL BLVD STE 203
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-8440
Practice Address - Country:US
Practice Address - Phone:504-887-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA72921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program