=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245306463
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARRETT ANDREW BETHKE D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21715 KINGSLAND BLVD SUITE 105
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-492-6064
-----------------------------------------------------
Fax | 281-579-1808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7011 MORNING SKY
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-0155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-693-0833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22291
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------