Healthcare Provider Details

I. General information

NPI: 1285709089
Provider Name (Legal Business Name): LANDON PAUL GILLETT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5307-A AIRPORT BLVD
AUSTIN TX
78751
US

IV. Provider business mailing address

812 E 47TH STREET UNIT A
AUSTIN TX
78751
US

V. Phone/Fax

Practice location:
  • Phone: 512-489-0474
  • Fax: 512-458-3033
Mailing address:
  • Phone: 512-489-0474
  • Fax: 512-458-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22681
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: