Healthcare Provider Details

I. General information

NPI: 1255348926
Provider Name (Legal Business Name): M M ORTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 DE ZAVALA RD
SAN ANTONIO TX
78249-2013
US

IV. Provider business mailing address

4422 DE ZAVALA RD
SAN ANTONIO TX
78249-2013
US

V. Phone/Fax

Practice location:
  • Phone: 210-696-3001
  • Fax: 210-764-1989
Mailing address:
  • Phone: 210-696-3001
  • Fax: 210-764-1989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number21086
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20402
License Number StateTX

VIII. Authorized Official

Name: DR. DIANA T MALONE
Title or Position: ORTHODONTIST
Credential: D.D.S.,M.S.
Phone: 210-696-3001