Healthcare Provider Details

I. General information

NPI: 1518313337
Provider Name (Legal Business Name): AUSTIN DSG, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 DAVIS LN SUITE #101
AUSTIN TX
78749-3683
US

IV. Provider business mailing address

1920 CORPORATE DR UNIT #107A
SAN MARCOS TX
78666-6283
US

V. Phone/Fax

Practice location:
  • Phone: 512-441-6200
  • Fax:
Mailing address:
  • Phone: 512-722-6338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number25904
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number25904
License Number StateTX

VIII. Authorized Official

Name: DR. PEJMAN KHOSRAVIAN
Title or Position: CEO
Credential: DMD
Phone: 512-722-6338