=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629158209
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY S O BRIEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 03/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1103 RIVERY BLVD SUITE 300
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-868-0238
-----------------------------------------------------
Fax | 512-868-9494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1103 RIVERY BLVD STE 300
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-3049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-868-0238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 13927
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------