MEDICARE: TEXDENTGROUP

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	1223G0001X	General Practice Dentistry	17310	TX

General Provider Information

NPI Number	:	1285915413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEXDENTGROUP

Provider Business Mailing Address
First Line	:	2609 PADINA DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78733-1666
Country	:	US
Telephone Number	:	512-569-5557
Fax Number	:	512-263-1490

Provider Business Practice Location Address
First Line	:	1802 ANDERSON LANE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757
Country	:	US
Telephone Number	:	512-459-4347
Fax Number	:	512-459-4348

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT HEWITT
Credential	:
Telephone Number	:	512-762-0378

Provider Enumeration Date	:	09/01/2011
Last Update Date	:	09/01/2011

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