Healthcare Provider Details

I. General information

NPI: 1194874818
Provider Name (Legal Business Name): CATHERINE BRIGID MC KINLEY BDENTSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CATHERINE BRIGID MAHON BDENTSC

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 FREDERICKSBURG RD SEVILLE OFFICE PARK
SAN ANTONIO TX
78229-3355
US

IV. Provider business mailing address

9876 DOS CERROS LOOP E
BOERNE TX
78006-5100
US

V. Phone/Fax

Practice location:
  • Phone: 210-614-3334
  • Fax: 210-614-3331
Mailing address:
  • Phone: 830-981-8978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number19466
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: