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NPI Code Detail

MEDICARE: LONE STAR PEDIATRIC DENTAL, PLLC

MEDICARE: LONE STAR PEDIATRIC 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
11223P0221XPediatric Dentistry24217TX

General Provider Information

NPI Number : 1376854364
Entity Type Code : Organization
Provider Name (Legal Business Name) : LONE STAR PEDIATRIC DENTAL, PLLC
Provider Business Mailing Address
First Line : 2700 S 1ST ST
Second Line :
City : AUSTIN
State : TX
Zip : 78704-5421
Country : US
Telephone Number : 512-442-4338
Fax Number : 512-442-6074
Provider Business Practice Location Address
First Line : 2700 S 1ST ST
Second Line :
City : AUSTIN
State : TX
Zip : 78704-5421
Country : US
Telephone Number : 512-442-4338
Fax Number : 512-442-6074
Authorized Official
Title or Position : OWNER
Name : DR. MARTY R MONTGOMERY
Credential : DMD
Telephone Number : 512-442-4338
Provider Enumeration Date : 06/24/2010
Last Update Date : 06/24/2010

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Directions to “LONE STAR PEDIATRIC DENTAL, PLLC ” Practice Location

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