Provider Demographics
NPI:1528413358
Name:SYNTHESIS DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:SYNTHESIS DENTAL GROUP PLLC
Other - Org Name:AQUARIO ORTHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODEN-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:832-203-7968
Mailing Address - Street 1:5656 BEE CAVES RD
Mailing Address - Street 2:STE B104
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746
Mailing Address - Country:US
Mailing Address - Phone:832-203-7968
Mailing Address - Fax:
Practice Address - Street 1:900 S WAYSIDE DR
Practice Address - Street 2:STE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77023-3427
Practice Address - Country:US
Practice Address - Phone:832-203-7968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty