1366643496 NPI number — SAN PEDRO DENTAL ASSOCIATES, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366643496 NPI number — SAN PEDRO DENTAL ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN PEDRO DENTAL ASSOCIATES, PC
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:
Provider Other Organization Name Type Code:
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:
1366643496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16414 SAN PEDRO AVE
Provider Second Line Business Mailing Address:
#200
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78232-2277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-499-0009
Provider Business Mailing Address Fax Number:
210-499-0002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16414 SAN PEDRO AVE
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78232-2277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-499-0009
Provider Business Practice Location Address Fax Number:
210-499-0002
Provider Enumeration Date:
05/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUTTON
Authorized Official First Name:
EDIE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE ASSISTANT
Authorized Official Telephone Number:
830-981-9193

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  17072 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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