Provider Demographics
NPI:1386911634
Name:THE PARKSIDE DENTIST
Entity type:Organization
Organization Name:THE PARKSIDE DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:REX
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIONES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-280-1216
Mailing Address - Street 1:10001 S INTERSTATE 35
Mailing Address - Street 2:SUITE 305
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78747-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10001 S INTERSTATE 35
Practice Address - Street 2:SUITE 305
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78747-1701
Practice Address - Country:US
Practice Address - Phone:512-280-1216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX258591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty