1356351456 NPI number — M M ORTHODONTICS PA

Table of content: (NPI 1356351456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356351456 NPI number — M M ORTHODONTICS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M M ORTHODONTICS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
M & M ORTHODONTICS, PA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356351456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6735 FM 78
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78244-1367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-667-2929
Provider Business Mailing Address Fax Number:
210-661-2575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6735 FM 78
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78244-1367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-667-2929
Provider Business Practice Location Address Fax Number:
210-661-2575
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALONE
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
T
Authorized Official Title or Position:
ORTHODONTIST
Authorized Official Telephone Number:
210-667-2929

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  20402 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0400X , with the licence number: 21086 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 23783 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 142539905 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 174952502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1312131 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 142539907 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142539904 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 174951702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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