Healthcare Provider Details

I. General information

NPI: 1356997126
Provider Name (Legal Business Name): NORTHEAST CHILDREN'S DENTISTRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N SAN SABA STE 202
SAN ANTONIO TX
78207-3193
US

IV. Provider business mailing address

315 N SAN SABA STE 202
SAN ANTONIO TX
78207-3193
US

V. Phone/Fax

Practice location:
  • Phone: 210-223-3383
  • Fax: 210-223-1055
Mailing address:
  • Phone: 210-223-3383
  • Fax: 210-223-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

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