Healthcare Provider Details

I. General information

NPI: 1033733365
Provider Name (Legal Business Name): ERNESTO CARMONA JR DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10125A LAKE CREEK PKWY
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:
Mailing address:
  • Phone: 512-250-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: ERNESTO CARMONA
Title or Position: OWNER
Credential: DDS
Phone: 512-250-9444