Provider Demographics
NPI:1457821126
Name:SOUTH AUSTIN MICROENDODONTICS
Entity Type:Organization
Organization Name:SOUTH AUSTIN MICROENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ODEGARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-580-9973
Mailing Address - Street 1:2500 W WILLIAM CANNON DR STE 605
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 W WILLIAM CANNON DR STE 605
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5320
Practice Address - Country:US
Practice Address - Phone:512-442-1555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1093294852OtherNPI
TX1205861473OtherNPI
TX1588863054OtherNPI
TX1740293752OtherNPI