Healthcare Provider Details

I. General information

NPI: 1225362882
Provider Name (Legal Business Name): ERNESTO CARMONA JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10125 LAKE CREEK PKWY SUITE A
AUSTIN TX
78729-1711
US

IV. Provider business mailing address

10125A LAKE CREEK PKWY
AUSTIN TX
78729-1711
US

V. Phone/Fax

Practice location:
  • Phone: 512-250-9444
  • Fax: 512-250-9790
Mailing address:
  • Phone: 512-250-9444
  • Fax: 512-250-9790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number25028
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: