MEDICARE: CHILDREN'S DENTAL ARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	11935	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811249659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S DENTAL ARK

Provider Business Mailing Address
First Line	:	610 LANDA ST.
Second Line	:
City	:	NEW BRAUNFELS
State	:	TX
Zip	:	78130-6112
Country	:	US
Telephone Number	:	830-625-1234
Fax Number	:	830-625-3266

Provider Business Practice Location Address
First Line	:	19750 STATE HWY 46 W
Second Line	:	STE. 105
City	:	SPRING BRANCH
State	:	TX
Zip	:	78070-6881
Country	:	US
Telephone Number	:	830-625-1222
Fax Number	:	830-625-3266

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. CHERYL STASNY SELLERS
Credential	:	DDS
Telephone Number	:	830-625-1234

Provider Enumeration Date	:	10/03/2012
Last Update Date	:	10/03/2012

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Directions to “CHILDREN'S DENTAL ARK ” Practice Location

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