=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659860112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SW AUSTIN DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2018
-----------------------------------------------------
Last Update Date | 05/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 W WILLIAM CANNON DR STE A200
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78749-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-282-0277
-----------------------------------------------------
Fax | 512-282-7207
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6000 W WILLIAM CANNON DR STE A200
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78749-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-282-0277
-----------------------------------------------------
Fax | 512-282-7207
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KATHRYN ZOUMBOUKOS
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 541-520-1473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------