=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134703192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUSTIN KIDS TEETH - ORTHODONTICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2021
-----------------------------------------------------
Last Update Date | 05/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6012 W WILLIAM CANNON DR STE B102
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78749-1978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-288-0522
-----------------------------------------------------
Fax | 512-288-6506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6012 W WILLIAM CANNON DR STE B102
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78749-1978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-288-0522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ CEO
-----------------------------------------------------
Name | MELANIE BABOT
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 512-288-0522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------