MEDICARE: LAKE AUSTIN FAMILY DENTAL, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1144557497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE AUSTIN FAMILY DENTAL, PLLC

Provider Business Mailing Address
First Line	:	2504 LAKE AUSTIN BLVD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78703-4455
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2504 LAKE AUSTIN BLVD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78703-4455
Country	:	US
Telephone Number	:	512-474-5233
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAQUELYN MORRIS
Credential	:	DDS
Telephone Number	:	512-474-5233

Provider Enumeration Date	:	11/06/2009
Last Update Date	:	11/06/2009

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