MEDICARE: CELEBRACES CONGRESS PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1588245922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CELEBRACES CONGRESS PLLC

Provider Business Mailing Address
First Line	:	111 W WILLIAM CANNON DR STE 200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-5657
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 W WILLIAM CANNON DR STE 200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-5657
Country	:	US
Telephone Number	:	512-521-7000
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	CHAD HENDRICKS
Credential	:
Telephone Number	:	612-859-0444

Provider Enumeration Date	:	04/17/2021
Last Update Date	:	04/17/2021

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