MEDICARE: RDG PARMER LANE, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1275251134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RDG PARMER LANE, PLLC

Provider Business Mailing Address
First Line	:	1450 W PARMER LN
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78727-4501
Country	:	US
Telephone Number	:	512-795-0008
Fax Number	:

Provider Business Practice Location Address
First Line	:	1450 W PARMER LN
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78727-4501
Country	:	US
Telephone Number	:	512-795-0008
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	AMANDA LIGHTFOOT
Credential	:
Telephone Number	:	214-702-0708

Provider Enumeration Date	:	08/17/2022
Last Update Date	:	12/14/2022

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