=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518059245
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I & J DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 W STASSNEY LN SUITE #106
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78745-3178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-445-2444
-----------------------------------------------------
Fax | 512-445-2224
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 W STASSNEY LN SUITE #106
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78745-3178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-445-2444
-----------------------------------------------------
Fax | 512-445-2224
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECT OWNER
-----------------------------------------------------
Name | MR. MICHAEL SHAYNE ISTRE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 512-426-2619
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------