Healthcare Provider Details

I. General information

NPI: 1861783557
Provider Name (Legal Business Name): RANDALL KIES DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4029 S CAPITAL OF TEXAS HWY STE 109
AUSTIN TX
78704-7927
US

IV. Provider business mailing address

4029 S CAPITAL OF TEXAS HWY STE 109
AUSTIN TX
78704-7927
US

V. Phone/Fax

Practice location:
  • Phone: 512-445-5866
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21186
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number7037
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11098
License Number StateTX

VIII. Authorized Official

Name: DR. RANDALL KIES
Title or Position: OWNER
Credential: DDS
Phone: 512-445-5866