=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811352966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGETOWN FAMILY AND COSMETIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2015
-----------------------------------------------------
Last Update Date | 12/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 N AUSTIN AVE STE 319
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-4354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-864-9530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 N AUSTIN AVE STE 319
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-4354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-864-9530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SHARON MATHIAS
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 512-740-5813
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 26307
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------