Healthcare Provider Details

I. General information

NPI: 1407423312
Provider Name (Legal Business Name): MY LOCAL TEXAS DENTAL PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1583 E COMMON ST STE 205
NEW BRAUNFELS TX
78130-3174
US

IV. Provider business mailing address

1583 E COMMON ST STE 205
NEW BRAUNFELS TX
78130-3174
US

V. Phone/Fax

Practice location:
  • Phone: 830-625-2111
  • Fax:
Mailing address:
  • Phone: 830-625-2111
  • 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: MICHELLE JOHNSON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 509-315-8338