MEDICARE: SOLA SMILE 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1821897307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOLA SMILE PLLC

Provider Business Mailing Address
First Line	:	3106 FONTANA DR UNIT B
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-6332
Country	:	US
Telephone Number	:	214-663-5432
Fax Number	:

Provider Business Practice Location Address
First Line	:	8701 MENCHACA RD STE 200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78748-5383
Country	:	US
Telephone Number	:	512-614-6800
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. AUDREY SU
Credential	:	DDS
Telephone Number	:	214-663-5432

Provider Enumeration Date	:	03/10/2025
Last Update Date	:	03/12/2025

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