=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255845061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN L. BOOTH, DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2017
-----------------------------------------------------
Last Update Date | 12/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11851 JOLLYVILLE RD STE 201
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-345-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11851 JOLLYVILLE RD STE 201
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-345-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | STEVEN LESLIE BOOTH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 512-345-8800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 18052
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------