Provider Demographics
NPI:1356616825
Name:RIVER ROCK - AIRPORT, P.C.
Entity type:Organization
Organization Name:RIVER ROCK - AIRPORT, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-739-9440
Mailing Address - Street 1:PO BOX 2638
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-1817
Mailing Address - Country:US
Mailing Address - Phone:512-385-4700
Mailing Address - Fax:512-389-9797
Practice Address - Street 1:1192 AIRPORT BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-3176
Practice Address - Country:US
Practice Address - Phone:512-820-6927
Practice Address - Fax:512-262-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-17
Last Update Date:2012-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX234961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty