Healthcare Provider Details

I. General information

NPI: 1700157955
Provider Name (Legal Business Name): ACCESS DENTAL OF WILLIAM CANNON PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E WILLIAM CANNON DR STE 201
AUSTIN TX
78745-6671
US

IV. Provider business mailing address

8150 SPRINGWOOD DR # 150B
IRVING TX
75063-5810
US

V. Phone/Fax

Practice location:
  • Phone: 512-717-5353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22334
License Number StateTX

VIII. Authorized Official

Name: TIEN DINH PHAN
Title or Position: DENTIST
Credential: DMD
Phone: 817-531-3500