MEDICARE: AUSTIN CENTRAL PARK PEDIATRIC DENTISTRY

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	1223P0221X	Pediatric Dentistry	28784	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1619250123	OTHER		INDIVIDUAL NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639597222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN CENTRAL PARK PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	1005 W 38TH ST STE 200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78705-1042
Country	:	US
Telephone Number	:	512-330-4624
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 W 38TH ST STE 200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78705-1042
Country	:	US
Telephone Number	:	512-330-4624
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. DANIEL CRANDALL JOHNSON
Credential	:	DDS
Telephone Number	:	512-330-4624

Provider Enumeration Date	:	04/01/2014
Last Update Date	:	10/21/2024

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Practice Location Address:

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Directions to “AUSTIN CENTRAL PARK PEDIATRIC DENTISTRY ” Practice Location

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