MEDICARE: STEVEN LESTER VAN WICKLEN 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	14585	TX

General Provider Information

NPI Number	:	1396769402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN LESTER VAN WICKLEN D.D.S.

Provider Business Mailing Address
First Line	:	3901 S. LAMAR BLVD
Second Line	:	STE 480
City	:	AUSTIN
State	:	TX
Zip	:	78704
Country	:	US
Telephone Number	:	512-448-3131
Fax Number	:	512-448-3331

Provider Business Practice Location Address
First Line	:	3901 S. LAMAR BLVD
Second Line	:	STE 480
City	:	AUSTIN
State	:	TX
Zip	:	78704-8801
Country	:	US
Telephone Number	:	512-448-3131
Fax Number	:	512-448-3331

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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