1811077407 NPI number — NORTHWOODS DENTAL SPA

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 1811077407 NPI number — NORTHWOODS DENTAL SPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWOODS DENTAL SPA
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:
1811077407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18160 HWY 281 N
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-495-7800
Provider Business Mailing Address Fax Number:
210-495-7805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18160 HWY 281 NORTH
Provider Second Line Business Practice Location Address:
SUITE 104
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-495-7800
Provider Business Practice Location Address Fax Number:
210-495-7805
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLAESS
Authorized Official First Name:
IRENE
Authorized Official Middle Name:
KIANSKY
Authorized Official Title or Position:
OWNER DENTISTS
Authorized Official Telephone Number:
210-495-7800

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com