MEDICARE: TEXAS KIDS DENTAL CARE OF MONTANA VISTA, PA.

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	122300000X	Dentist	24362	TX

General Provider Information

NPI Number	:	1821368507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEXAS KIDS DENTAL CARE OF MONTANA VISTA, PA.

Provider Business Mailing Address
First Line	:	3650 JOE BATTLE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79938-2628
Country	:	US
Telephone Number	:	915-855-0948
Fax Number	:

Provider Business Practice Location Address
First Line	:	3650 JOE BATTLE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79938-2628
Country	:	US
Telephone Number	:	915-855-0948
Fax Number	:

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	PRISCILLA PORRAS
Credential	:
Telephone Number	:	915-855-0948

Provider Enumeration Date	:	01/11/2012
Last Update Date	:	02/06/2017

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