MEDICARE: DR. GERALD BERNARD PEVOW DMD

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	28628	TX
2	1223G0001X	General Practice Dentistry	28268	TX

General Provider Information

NPI Number	:	1558611087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERALD BERNARD PEVOW DMD

Provider Business Mailing Address
First Line	:	1802 W ANDERSON LN
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-1338
Country	:	US
Telephone Number	:	512-459-4347
Fax Number	:	512-459-4348

Provider Business Practice Location Address
First Line	:	1802 W ANDERSON LN
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-1338
Country	:	US
Telephone Number	:	512-459-4347
Fax Number	:	512-459-4348

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

Provider Enumeration Date	:	09/12/2012
Last Update Date	:	06/17/2021

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