Provider Demographics
NPI:1730282633
Name:RISING STARS PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:RISING STARS PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FREEZE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:512-266-7200
Mailing Address - Street 1:4308 N QUINLAN PARK
Mailing Address - Street 2:STE 201
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732
Mailing Address - Country:US
Mailing Address - Phone:512-266-7200
Mailing Address - Fax:512-266-6197
Practice Address - Street 1:4308 N QUINLAN PARK
Practice Address - Street 2:STE 201
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78732
Practice Address - Country:US
Practice Address - Phone:512-266-7200
Practice Address - Fax:512-266-6197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1620639OtherUNITED CONCORDIA