MEDICARE: LATIOLAIS KIMES 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	1223D0001X	Public Health Dentistry	24030	TX

General Provider Information

NPI Number	:	1881039212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LATIOLAIS KIMES DENTAL, PLLC

Provider Business Mailing Address
First Line	:	11420 BEE CAVES RD
Second Line	:	STE B150
City	:	AUSTIN
State	:	TX
Zip	:	78738-5526
Country	:	US
Telephone Number	:	512-263-8500
Fax Number	:	512-263-2866

Provider Business Practice Location Address
First Line	:	11420 BEE CAVES RD
Second Line	:	STE B150
City	:	AUSTIN
State	:	TX
Zip	:	78738-5526
Country	:	US
Telephone Number	:	512-263-8500
Fax Number	:	512-263-2866

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NICOLE E LATIOLAIS
Credential	:	DDS
Telephone Number	:	512-263-8500

Provider Enumeration Date	:	04/29/2013
Last Update Date	:	04/29/2013

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