=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518535350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAMPION SMILES PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2021
-----------------------------------------------------
Last Update Date | 07/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 ED SCHMIDT BLVD STE 240
-----------------------------------------------------
City | HUTTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78634-5588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-982-1500
-----------------------------------------------------
Fax | 512-846-2845
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 ED SCHMIDT BLVD STE 240
-----------------------------------------------------
City | HUTTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78634-5588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-982-1500
-----------------------------------------------------
Fax | 512-846-2845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DEEPA NAIK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 512-982-1500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------