Provider Demographics
NPI:1093729923
Name:AUSTIN CHILDRENS DENTISTRY
Entity Type:Organization
Organization Name:AUSTIN CHILDRENS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:UPDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:512-682-5437
Mailing Address - Street 1:12501 HYMEADOW DR STE 1A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1831
Mailing Address - Country:US
Mailing Address - Phone:512-682-5437
Mailing Address - Fax:512-258-1615
Practice Address - Street 1:12501 HYMEADOW DR STE 1A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1831
Practice Address - Country:US
Practice Address - Phone:512-682-5437
Practice Address - Fax:512-258-1615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty