MEDICARE: WE DENTAL, PLLC

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

General Provider Information

NPI Number	:	1205202157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WE DENTAL, PLLC

Provider Business Mailing Address
First Line	:	10009 N LAMAR BLVD
Second Line	:	SUITE C
City	:	AUSTIN
State	:	TX
Zip	:	78753-4117
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10009 N LAMAR BLVD
Second Line	:	SUITE C
City	:	AUSTIN
State	:	TX
Zip	:	78753-4117
Country	:	US
Telephone Number	:	719-243-2378
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	LUCAS M EBAUGH
Credential	:
Telephone Number	:	719-243-2378

Provider Enumeration Date	:	08/14/2015
Last Update Date	:	08/14/2015

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