Healthcare Provider Details

I. General information

NPI: 1982338513
Provider Name (Legal Business Name): ALAMO CITY ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NW LOOP 410 STE 560
SAN ANTONIO TX
78213-2257
US

IV. Provider business mailing address

PO BOX 356
LYTLE TX
78052-0356
US

V. Phone/Fax

Practice location:
  • Phone: 210-344-9295
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOANNA AYALA
Title or Position: MANAGING MEMBER
Credential:
Phone: 210-632-4560