Healthcare Provider Details

I. General information

NPI: 1649607003
Provider Name (Legal Business Name): LYTLE PEDIATRIC DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19315 MCDONALD ST
LYTLE TX
78052-3622
US

IV. Provider business mailing address

PO BOX 356
LYTLE TX
78052
US

V. Phone/Fax

Practice location:
  • Phone: 830-772-5600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number24255
License Number StateTX

VIII. Authorized Official

Name: JOANNA AYALA
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 210-632-4560