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General NPI Number Information
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NPI Number | 1215629340
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Entity Type | Organization
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Legal Business Name | EAST AUSTIN ORAL SURGERY PLLC
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Dates
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Enumeration Date | 05/25/2023
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Last Update Date | 06/14/2024
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Provider Practice Location Address
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Address Line | 2832 E MLK BLVD APT 102
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City | AUSTIN
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State | TX
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Zip | 78702-1504
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Country | US
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Telephone | 210-846-3890
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Fax |
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Provider Business Mailing Address
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Address Line | 5001 WESTVIEW DR
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City | AUSTIN
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State | TX
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Zip | 78731-4737
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MATTHEW LARGENT
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Credential | MD DDS
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Telephone | 210-846-3890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State |
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