1033765094 NPI number — NORTHEAST CHILDREN'S DENTISTRY, INC

Table of content: (NPI 1033765094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033765094 NPI number — NORTHEAST CHILDREN'S DENTISTRY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST CHILDREN'S DENTISTRY, INC
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:
6
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:
1033765094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21727 IH 10 W STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78257-2107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-314-4545
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21727 IH 10 W STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78257-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-314-4545
Provider Business Practice Location Address Fax Number:
210-314-4596
Provider Enumeration Date:
08/15/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HAY
Authorized Official First Name:
TRACEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE COORDINATOR
Authorized Official Telephone Number:
210-654-6882

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00K78 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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