Provider Demographics
NPI:1215259684
Name:SOUTHPARK SMILES, PC
Entity type:Organization
Organization Name:SOUTHPARK SMILES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-282-7200
Mailing Address - Street 1:9500 SOUTH IH 35
Mailing Address - Street 2:SUITE E 400
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-1990
Mailing Address - Country:US
Mailing Address - Phone:512-282-7200
Mailing Address - Fax:512-282-7204
Practice Address - Street 1:4410 E RIVERSIDE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-4799
Practice Address - Country:US
Practice Address - Phone:512-385-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty