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General NPI Number Information
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NPI Number | 1073834586
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Entity Type | Organization
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Legal Business Name | DENTAL STUDIO
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Dates
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Enumeration Date | 06/18/2010
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Last Update Date | 04/21/2015
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Provider Practice Location Address
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Address Line | 1671 MAIN ST STE B
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City | BUDA
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State | TX
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Zip | 78610-9732
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Country | US
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Telephone | 512-295-5777
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Fax | 512-295-5030
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Provider Business Mailing Address
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Address Line | 1671 MAIN ST STE B
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City | BUDA
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State | TX
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Zip | 78610-9732
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Country | US
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Telephone | 512-295-5777
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Fax | 512-295-5030
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROSS M KOEPPEN
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Credential | DDS
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Telephone | 512-295-5777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0025123
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License Number State | TX
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