Healthcare Provider Details

I. General information

NPI: 1336515436
Provider Name (Legal Business Name): PROSTHODONTICS OF TEXAS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 DAVIS LANE SUITE 101
AUSTIN TX
78749
US

IV. Provider business mailing address

5301 DAVIS LANE SUITE 101
AUSTIN TX
78749
US

V. Phone/Fax

Practice location:
  • Phone: 512-960-4225
  • Fax: 512-960-4800
Mailing address:
  • Phone: 512-960-4225
  • Fax: 512-960-4800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number28864
License Number StateTX

VIII. Authorized Official

Name: DR. STEWART WHITNEY PHARR
Title or Position: OWNER
Credential: DMD
Phone: 512-960-4225