=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659898997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J.W. DENTAL ASSOCIATES ANDERSON LTD., LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2017
-----------------------------------------------------
Last Update Date | 08/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 W ANDERSON LN
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78757-1336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-329-9900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 162322
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78716-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANGER
-----------------------------------------------------
Name | JOYCE WONG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 512-329-9900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30459
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 24821
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------