Provider Demographics
NPI:1922259266
Name:SOUTHPARK SMILES,PC
Entity Type:Organization
Organization Name:SOUTHPARK SMILES,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-739-9440
Mailing Address - Street 1:1603 NASH AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-3331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9500 S INTERSTATE 35
Practice Address - Street 2:SUITE E-400
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-1752
Practice Address - Country:US
Practice Address - Phone:512-282-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty