=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679086599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAKER LANE DENTAL HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2017
-----------------------------------------------------
Last Update Date | 11/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1139 BRAKER LANE 201
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-326-3473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 W. WILLIAM CANNON DR 438A
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-326-3473
-----------------------------------------------------
Fax | 512-326-5439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | MRS. ASHA PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-326-3473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------