Provider Demographics
NPI:1447595855
Name:ROCK THAT SMILE PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:ROCK THAT SMILE PEDIATRIC DENTISTRY PLLC
Other - Org Name:LAKELINE RISING STARS PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:GREGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:512-266-7200
Mailing Address - Street 1:14005 N. HWY 183
Mailing Address - Street 2:# 800
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717
Mailing Address - Country:US
Mailing Address - Phone:512-266-7200
Mailing Address - Fax:512-583-0675
Practice Address - Street 1:14005 N. HWY 183
Practice Address - Street 2:#800
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717
Practice Address - Country:US
Practice Address - Phone:512-266-7200
Practice Address - Fax:512-583-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty