MEDICARE: BO JAMES STANLEY 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	D12925	MN

General Provider Information

NPI Number	:	1316233893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BO JAMES STANLEY D.D.S.

Provider Business Mailing Address
First Line	:	3901 S LAMAR BLVD STE 400
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-7990
Country	:	US
Telephone Number	:	512-442-7897
Fax Number	:

Provider Business Practice Location Address
First Line	:	3901 S LAMAR BLVD STE 400
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-7990
Country	:	US
Telephone Number	:	512-442-7897
Fax Number	:

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

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	09/16/2019

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