Healthcare Provider Details

I. General information

NPI: 1821520487
Provider Name (Legal Business Name): CONNIE L AUSTIN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 33100 BOX LANDSTUHL
APO AE
09180-3100
US

IV. Provider business mailing address

CMR 427 BOX 2404
APO AE
09630-0025
US

V. Phone/Fax

Practice location:
  • Phone: 314-636-9748
  • Fax:
Mailing address:
  • Phone: 314-636-9748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number102740
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number102740
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number11165
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number102740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: