MEDICARE: DR. AUDREY SU D.D.S

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	30990	TX

General Provider Information

NPI Number	:	1295116416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUDREY SU D.D.S

Provider Business Mailing Address
First Line	:	3106 FONTANA DR UNIT B
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-6332
Country	:	US
Telephone Number	:	214-663-5432
Fax Number	:

Provider Business Practice Location Address
First Line	:	8701 MENCHACA RD STE 200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78748-5383
Country	:	US
Telephone Number	:	214-663-5432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2015
Last Update Date	:	03/12/2025

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