Provider Demographics
NPI:1689917106
Name:BANYAN TREE DENTAL, P.A.
Entity Type:Organization
Organization Name:BANYAN TREE DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-382-7123
Mailing Address - Street 1:11416 FM 620 STE N
Mailing Address - Street 2:SUITE K
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-1165
Mailing Address - Country:US
Mailing Address - Phone:512-382-7123
Mailing Address - Fax:
Practice Address - Street 1:11416 FM 620 STE N
Practice Address - Street 2:SUITE K
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78726-1165
Practice Address - Country:US
Practice Address - Phone:512-382-7123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX191431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty