MEDICARE: KACIE MARIE CULOTTA D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	29962	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29962	OTHER	TX	TEXAS STATE DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1104239615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KACIE MARIE CULOTTA D.M.D.

Provider Business Mailing Address
First Line	:	11671 JOLLYVILLE RD STE 204
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-4141
Country	:	US
Telephone Number	:	512-345-9973
Fax Number	:

Provider Business Practice Location Address
First Line	:	11671 JOLLYVILLE RD STE 204
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-4141
Country	:	US
Telephone Number	:	512-345-9973
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2014
Last Update Date	:	05/22/2024

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