MEDICARE: KING SMILES IV, PA

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

General Provider Information

NPI Number	:	1578717039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KING SMILES IV, PA

Provider Business Mailing Address
First Line	:	2407 S CONGRESS AVE
Second Line	:	100
City	:	AUSTIN
State	:	TX
Zip	:	78704-5505
Country	:	US
Telephone Number	:	512-832-6225
Fax Number	:	512-832-8448

Provider Business Practice Location Address
First Line	:	2407 S CONGRESS AVE
Second Line	:	100
City	:	AUSTIN
State	:	TX
Zip	:	78704-5505
Country	:	US
Telephone Number	:	512-832-6225
Fax Number	:	512-832-8448

Authorized Official
Title or Position	:	INSURANCE COORDINATOR
Name	:	JULIAN FONCELL POWERS
Credential	:
Telephone Number	:	512-832-6225

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	11/11/2008

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