Provider Demographics
NPI:1194021154
Name:AUSTIN PROFESSIONAL DENTAL
Entity Type:Organization
Organization Name:AUSTIN PROFESSIONAL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JAZMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-982-8490
Mailing Address - Street 1:5400 LYNDON B JOHNSON FWY
Mailing Address - Street 2:SUITE 944
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1000
Mailing Address - Country:US
Mailing Address - Phone:972-982-8490
Mailing Address - Fax:
Practice Address - Street 1:615 W SLAUGHTER LN
Practice Address - Street 2:SUITE 117
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-2094
Practice Address - Country:US
Practice Address - Phone:512-233-6825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX229581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty