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NPI Code Detail

MEDICARE: SOUTH AUSTIN MICROENDODONTICS

MEDICARE: SOUTH AUSTIN MICROENDODONTICS
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
11223E0200XEndodontics

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11093294852OTHERTXNPI
21205861473OTHERTXNPI
31588863054OTHERTXNPI
41740293752OTHERTXNPI

General Provider Information

NPI Number : 1457821126
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTH AUSTIN MICROENDODONTICS
Provider Business Mailing Address
First Line : 2500 W WILLIAM CANNON DR STE 605
Second Line :
City : AUSTIN
State : TX
Zip : 78745-5320
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2500 W WILLIAM CANNON DR STE 605
Second Line :
City : AUSTIN
State : TX
Zip : 78745-5320
Country : US
Telephone Number : 512-442-1555
Fax Number :
Authorized Official
Title or Position : OPERATIONS MANAGER
Name : MEGAN ODEGARD
Credential :
Telephone Number : 512-580-9973
Provider Enumeration Date : 11/26/2018
Last Update Date : 11/26/2018

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Directions to “SOUTH AUSTIN MICROENDODONTICS ” Practice Location

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