Healthcare Provider Details

I. General information

NPI: 1740643634
Provider Name (Legal Business Name): NICHOLAS BUMACOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 W SLAUGHTER LN STE 470C
AUSTIN TX
78749-6513
US

IV. Provider business mailing address

505 E HUNTLAND DR STE 340
AUSTIN TX
78752-3745
US

V. Phone/Fax

Practice location:
  • Phone: 512-288-1900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number33964
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: