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General NPI Number Information
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NPI Number | 1538559422
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Entity Type | Organization
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Legal Business Name | SENIOR SMILES PA
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Dates
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Enumeration Date | 01/29/2015
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Last Update Date | 01/29/2015
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Provider Practice Location Address
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Address Line | 2550 S IH 35 SUITE 215
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City | AUSTIN
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State | TX
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Zip | 78704-5722
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Country | US
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Telephone | 512-381-5572
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Fax | 888-503-5605
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Provider Business Mailing Address
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Address Line | PO BOX 41266
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City | AUSTIN
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State | TX
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Zip | 78704-0022
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Country | US
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Telephone | 512-381-5572
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Fax | 888-503-5605
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Authorized Official
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Title or Position | PRESIDENT & OWNER
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Name | DR. GREGORY KON
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Credential | DDS
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Telephone | 512-381-5572
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 25128
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License Number State | TX
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