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General NPI Number Information
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NPI Number | 1679071633
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Entity Type | Organization
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Legal Business Name | BLUE SKY FAMILY DENTISTRY
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Dates
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Enumeration Date | 01/24/2018
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Last Update Date | 01/24/2018
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Provider Practice Location Address
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Address Line | 5915 LA CROSSE AVE STE 105
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City | AUSTIN
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State | TX
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Zip | 78739-1747
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Country | US
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Telephone | 919-740-5096
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Fax |
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Provider Business Mailing Address
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Address Line | 1905 CROOKED LN
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City | AUSTIN
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State | TX
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Zip | 78741-3907
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BEN CORPRON
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Credential | DDS
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Telephone | 919-740-5096
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 33478
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License Number State | TX
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