=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275296717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONE STAR DENTAL CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2021
-----------------------------------------------------
Last Update Date | 10/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3407 WELLS BRANCH PKWY STE 700
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78728-6619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-244-7677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3407 WELLS BRANCH PKWY STE 700
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78728-6619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-244-7677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF DENTAL OFFICER
-----------------------------------------------------
Name | DR. HARISH GOGINENI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 732-986-4338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------