Provider Demographics
NPI:1821407040
Name:CEDAR PARK PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:CEDAR PARK PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BERT
Authorized Official - Middle Name:
Authorized Official - Last Name:VASUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-258-8888
Mailing Address - Street 1:2051 CYPRESS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3623
Mailing Address - Country:US
Mailing Address - Phone:512-258-8888
Mailing Address - Fax:
Practice Address - Street 1:2051 CYPRESS CREEK RD
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3623
Practice Address - Country:US
Practice Address - Phone:512-258-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty