Provider Demographics
NPI:1548977895
Name:SHINE PEDIATRIC DENTAL CO.
Entity type:Organization
Organization Name:SHINE PEDIATRIC DENTAL CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-698-8766
Mailing Address - Street 1:608 TWELVE OAKS LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2631 GATTIS SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2821
Practice Address - Country:US
Practice Address - Phone:512-698-8766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty