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General NPI Number Information
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NPI Number | 1114415163
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Entity Type | Organization
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Legal Business Name | IMYO: OROFACIAL MYOLOGY OF CENTRAL TEXAS
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Dates
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Enumeration Date | 04/25/2018
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Last Update Date | 12/30/2020
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Provider Practice Location Address
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Address Line | 4749 WILLIAMS DR STE 334450
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City | GEORGETOWN
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State | TX
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Zip | 78633-3710
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Country | US
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Telephone | 512-826-2527
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Fax |
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Provider Business Mailing Address
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Address Line | 4749 WILLIAMS DR STE 334450
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City | GEORGETOWN
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State | TX
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Zip | 78633-3710
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Country | US
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Telephone | 512-826-2527
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Fax |
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Authorized Official
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Title or Position | CERTIFIED OROFACIAL MYOLOGIST
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Name | MRS. JESSICA N. CAIN
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Credential | BSRDH.COM
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Telephone | 512-826-2527
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 14525
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License Number State | TX
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