=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639497555
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDTOWN DENTAL ASSOCIATES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2010
-----------------------------------------------------
Last Update Date | 05/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 E 30TH ST #306
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78705-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-472-2246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 E 30TH ST #306
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78705-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-472-2246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | CATHERINE WOOTTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-472-2246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12773
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------