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General NPI Number Information
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NPI Number | 1851667729
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Entity Type | Organization
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Legal Business Name | QUINLAN PARK DENTAL
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Dates
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Enumeration Date | 03/26/2012
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Last Update Date | 03/26/2012
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Provider Practice Location Address
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Address Line | 5145 N. FM 620 SUITE G-150
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City | AUSTIN
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State | TX
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Zip | 78732
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Country | US
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Telephone | 512-619-3514
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Fax |
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Provider Business Mailing Address
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Address Line | 5145 N. FM 620 SUITE G-150
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City | AUSTIN
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State | TX
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Zip | 78732
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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 | SUMITA CHAKRABORTI
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Credential |
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Telephone | 512-619-3514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 23056
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License Number State | TX
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