=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689465106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE TRAVIS DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2025
-----------------------------------------------------
Last Update Date | 05/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3807 RANCH ROAD 620 N
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78734-2177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-382-6985
-----------------------------------------------------
Fax | 512-579-0016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3807 RANCH ROAD 620 N
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78734-2177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-382-6985
-----------------------------------------------------
Fax | 512-579-0016
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. KIRPAL TOOR
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 512-382-6985
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------