Healthcare Provider Details

I. General information

NPI: 1417675372
Provider Name (Legal Business Name): AVERY RANCH DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15004 AVERY RANCH BLVD # 100
AUSTIN TX
78717-4600
US

IV. Provider business mailing address

15004 AVERY RANCH BLVD # 100
AUSTIN TX
78717-4600
US

V. Phone/Fax

Practice location:
  • Phone: 512-246-7645
  • Fax:
Mailing address:
  • Phone: 512-246-7645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: AMANDA LIGHTFOOT
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 214-702-0708