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General NPI Number Information
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NPI Number | 1417135625
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Entity Type | Organization
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Legal Business Name | CRYSTAL FALLS FAMILY DENTISTRY, PLLC
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Dates
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Enumeration Date | 02/11/2008
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Last Update Date | 06/23/2008
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Provider Practice Location Address
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Address Line | 10703 E CRYSTAL FALLS PKWY
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City | LEANDER
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State | TX
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Zip | 78641-2259
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Country | US
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Telephone | 512-260-9333
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Fax | 512-260-9331
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Provider Business Mailing Address
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Address Line | 10703 E CRYSTAL FALLS PKWY
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City | LEANDER
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State | TX
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Zip | 78641-2259
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Country | US
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Telephone | 512-260-9333
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Fax | 512-260-9331
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Authorized Official
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Title or Position | OWNER
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Name | DR. JONATHAN DANIEL TUCKER
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Credential | D.D.S.
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Telephone | 512-260-9333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 22102
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License Number State | TX
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