Healthcare Provider Details

I. General information

NPI: 1932328333
Provider Name (Legal Business Name): CENTRAL TEXAS PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 N. AUSTIN AVE. SUITE 101
GEORGETOWN TX
78626
US

IV. Provider business mailing address

1811 N. AUSTIN AVE. SUITE 101
GEORGETOWN TX
78626
US

V. Phone/Fax

Practice location:
  • Phone: 512-863-9500
  • Fax: 512-863-9562
Mailing address:
  • Phone: 512-863-9500
  • Fax: 512-863-9562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number20343
License Number StateTX

VIII. Authorized Official

Name: DR. JONATHAN R CALLIA
Title or Position: DENTIST
Credential: D.D.S., M.S.
Phone: 512-863-9500