=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497991210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUSTIN PRIMARY DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2008
-----------------------------------------------------
Last Update Date | 12/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 W GATE BLVD STE 103
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78745-4867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-440-1333
-----------------------------------------------------
Fax | 512-440-0484
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6700 W GATE BLVD STE 103
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78745-4867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-440-1333
-----------------------------------------------------
Fax | 512-440-0484
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAYASHREE KYATAM
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 512-440-1333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22247
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------