MEDICARE: STASSNEY SMILES, P.C.

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	23496	TX

General Provider Information

NPI Number	:	1801218854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STASSNEY SMILES, P.C.

Provider Business Mailing Address
First Line	:	4410 E RIVERSIDE DR
Second Line	:	SUITE 150
City	:	AUSTIN
State	:	TX
Zip	:	78741-4799
Country	:	US
Telephone Number	:	512-206-4484
Fax Number	:	512-206-4993

Provider Business Practice Location Address
First Line	:	5717 SOUTH IH 35
Second Line	:	BLDG B SUITE #101
City	:	AUSTIN
State	:	TX
Zip	:	78744
Country	:	US
Telephone Number	:	512-462-4775
Fax Number	:	512-462-4782

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JACKSON BOOTH
Credential	:	DDS
Telephone Number	:	512-739-9440

Provider Enumeration Date	:	01/10/2014
Last Update Date	:	01/10/2014

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