=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225362882
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERNESTO CARMONA JR. D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2009
-----------------------------------------------------
Last Update Date | 12/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10125 LAKE CREEK PKWY SUITE A
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78729-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-250-9444
-----------------------------------------------------
Fax | 512-250-9790
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10125A LAKE CREEK PKWY
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78729-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-250-9444
-----------------------------------------------------
Fax | 512-250-9790
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 25028
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------