Healthcare Provider Details

I. General information

NPI: 1588303275
Provider Name (Legal Business Name): MY LOCAL TEXAS DENTAL PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N VISTA RIDGE BLVD STE 100
CEDAR PARK TX
78613-2425
US

IV. Provider business mailing address

6110 BARNES RD
COLORADO SPRINGS CO
80922-2600
US

V. Phone/Fax

Practice location:
  • Phone: 512-250-2356
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GREGORY KOSTELAC
Title or Position: DATA ANALYST
Credential:
Phone: 719-372-5605