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General NPI Number Information
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NPI Number | 1235402371
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Entity Type | Organization
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Legal Business Name | SMILE 360 PLLC
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Dates
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Enumeration Date | 02/21/2012
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Last Update Date | 05/16/2013
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Provider Practice Location Address
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Address Line | 1509 S LAMAR BLVD SUITE 675
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City | AUSTIN
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State | TX
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Zip | 78704
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Country | US
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Telephone | 512-444-4746
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Fax | 512-442-4750
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Provider Business Mailing Address
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Address Line | 1509 S. LAMAR BLVD #675
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City | AUSTIN
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State | TX
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Zip | 78704
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Country | US
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Telephone | 512-444-4746
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Fax | 512-442-4750
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Authorized Official
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Title or Position | DENTIST
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Name | DR. VINCENT KING IP
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Credential | D.D.S.
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Telephone | 512-814-2084
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22901
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License Number State | TX
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