MEDICARE: MRS. BRANDY MARIE TABOR RDH

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	124Q00000X	Dental Hygienist	13525	TX

General Provider Information

NPI Number	:	1578934808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRANDY MARIE TABOR RDH

Provider Business Mailing Address
First Line	:	2411 WILLIAMS DR
Second Line	:	SUITE 111
City	:	GEORGETOWN
State	:	TX
Zip	:	78628-3271
Country	:	US
Telephone Number	:	512-864-1445
Fax Number	:	512-864-1447

Provider Business Practice Location Address
First Line	:	2411 WILLIAMS DR
Second Line	:	SUITE 111
City	:	GEORGETOWN
State	:	TX
Zip	:	78628-3271
Country	:	US
Telephone Number	:	512-864-1445
Fax Number	:	512-864-1447

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

Provider Enumeration Date	:	10/13/2015
Last Update Date	:	10/13/2015

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