Healthcare Provider Details

I. General information

NPI: 1447595855
Provider Name (Legal Business Name): ROCK THAT SMILE PEDIATRIC DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14005 N. HWY 183 #800
AUSTIN TX
78717
US

IV. Provider business mailing address

14005 N. HWY 183 # 800
AUSTIN TX
78717
US

V. Phone/Fax

Practice location:
  • Phone: 512-266-7200
  • Fax: 512-583-0675
Mailing address:
  • Phone: 512-266-7200
  • Fax: 512-583-0675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY B GREGERSON
Title or Position: OWNER
Credential: D.M.D.
Phone: 512-266-7200