Healthcare Provider Details

I. General information

NPI: 1750551925
Provider Name (Legal Business Name): CAPITAL ORTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10119 LAKE CREEK PKWY STE 1
AUSTIN TX
78729-1757
US

IV. Provider business mailing address

10119 LAKE CREEK PKWY STE 1
AUSTIN TX
78729-1757
US

V. Phone/Fax

Practice location:
  • Phone: 512-258-6979
  • Fax: 512-250-0381
Mailing address:
  • Phone: 512-258-6979
  • Fax: 512-250-0381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number19179
License Number StateTX

VIII. Authorized Official

Name: DR. FARRAH AGAHI
Title or Position: PRESIDENT
Credential: DMD
Phone: 512-258-6979