=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528413358
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYNTHESIS DENTAL GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2016
-----------------------------------------------------
Last Update Date | 04/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 S WAYSIDE DR STE 100
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77023-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-203-7968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5656 BEE CAVES RD STE B104
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-203-7968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DUSTN RODEN-JOHNSON
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 832-203-7968
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 22109
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------