=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790167617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALI GOLSHANI D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2015
-----------------------------------------------------
Last Update Date | 03/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5329 SERENE HILLS DR STE 104
-----------------------------------------------------
City | LAKEWAY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78738-1257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-334-0345
-----------------------------------------------------
Fax | 512-870-9803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5329 SERENE HILLS DR STE 104
-----------------------------------------------------
City | LAKEWAY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78738-1257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-334-0345
-----------------------------------------------------
Fax | 512-870-9803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 31091
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------