Healthcare Provider Details

I. General information

NPI: 1760117303
Provider Name (Legal Business Name): DMDLE,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 OLD FREDERICKSBURG RD STE D102
AUSTIN TX
78749-1210
US

IV. Provider business mailing address

5901 OLD FREDERICKSBURG RD STE D102
AUSTIN TX
78749-1210
US

V. Phone/Fax

Practice location:
  • Phone: 512-892-9900
  • Fax:
Mailing address:
  • Phone: 951-231-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL LE
Title or Position: OWNER
Credential: DMD
Phone: 951-231-7246