MEDICARE: DR. DALLAS JAN KROMMENHOEK 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	122300000X	Dentist	24849	TX

General Provider Information

NPI Number	:	1477783132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALLAS JAN KROMMENHOEK D.D.S.

Provider Business Mailing Address
First Line	:	4105 WESTBANK DR
Second Line	:	#103
City	:	AUSTIN
State	:	TX
Zip	:	78746-4455
Country	:	US
Telephone Number	:	512-327-6908
Fax Number	:	512-327-6695

Provider Business Practice Location Address
First Line	:	4105 WESTBANK DR
Second Line	:	#103
City	:	AUSTIN
State	:	TX
Zip	:	78746-4455
Country	:	US
Telephone Number	:	512-327-6908
Fax Number	:	512-327-6695

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

Provider Enumeration Date	:	07/15/2009
Last Update Date	:	02/15/2013

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