Healthcare Provider Details

I. General information

NPI: 1881039212
Provider Name (Legal Business Name): LATIOLAIS KIMES DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11420 BEE CAVES RD STE B150
AUSTIN TX
78738-5526
US

IV. Provider business mailing address

11420 BEE CAVES RD STE B150
AUSTIN TX
78738-5526
US

V. Phone/Fax

Practice location:
  • Phone: 512-263-8500
  • Fax: 512-263-2866
Mailing address:
  • Phone: 512-263-8500
  • Fax: 512-263-2866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number24030
License Number StateTX

VIII. Authorized Official

Name: DR. NICOLE E LATIOLAIS
Title or Position: OWNER
Credential: DDS
Phone: 512-263-8500