Healthcare Provider Details

I. General information

NPI: 1386752855
Provider Name (Legal Business Name): MARTIN J SHEDECK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 UNIVERSITY DR #101 LONGHORN DENTAL
GEORGETOWN TX
78626
US

IV. Provider business mailing address

7517 CAMERON ROAD SUITE 107 LONGHORN DENTAL
AUSTIN TX
78752
US

V. Phone/Fax

Practice location:
  • Phone: 512-930-5930
  • Fax: 512-869-0276
Mailing address:
  • Phone: 512-371-1222
  • Fax: 512-371-3914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22728
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: