Healthcare Provider Details

I. General information

NPI: 1962833996
Provider Name (Legal Business Name): METRO PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 38TH ST STE G5
AUSTIN TX
78705-1121
US

IV. Provider business mailing address

711 W 38TH ST STE G5
AUSTIN TX
78705
US

V. Phone/Fax

Practice location:
  • Phone: 512-453-1600
  • Fax: 512-453-1503
Mailing address:
  • Phone: 512-453-1600
  • Fax: 512-453-1503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER MARK BINGAHAM
Title or Position: OWNER
Credential: DDS
Phone: 512-453-1600