Healthcare Provider Details

I. General information

NPI: 1245252238
Provider Name (Legal Business Name): NORTHEAST CHILDREN'S DENTISTRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8606 VILLAGE DR STE. B
SAN ANTONIO TX
78217-5506
US

IV. Provider business mailing address

8606 VILLAGE DR STE. B
SAN ANTONIO TX
78217-5506
US

V. Phone/Fax

Practice location:
  • Phone: 210-654-6882
  • Fax: 210-654-0036
Mailing address:
  • Phone: 210-654-6882
  • Fax: 210-654-0036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number11694
License Number StateTX

VIII. Authorized Official

Name: TRACEY HAY
Title or Position: PRACTICE COORDINATOR
Credential:
Phone: 210-654-6882