Healthcare Provider Details

I. General information

NPI: 1649330655
Provider Name (Legal Business Name): DIMA KALAKECH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 FREDERICKSBURG RD SUITE 103
SAN ANTONIO TX
78201-2031
US

IV. Provider business mailing address

1218 SW MILITARY DR
SAN ANTONIO TX
78221-1535
US

V. Phone/Fax

Practice location:
  • Phone: 210-734-9551
  • Fax:
Mailing address:
  • Phone: 210-734-9551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number21509
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: