Healthcare Provider Details

I. General information

NPI: 1871863043
Provider Name (Legal Business Name): CAROUSEL DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1844 NACOGDOCHES ROAD
SAN ANTONIO TX
78209-2216
US

IV. Provider business mailing address

1844 NACOGDOCHES ROAD
SAN ANTONIO TX
78209-2216
US

V. Phone/Fax

Practice location:
  • Phone: 210-824-0152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number15729
License Number StateTX

VIII. Authorized Official

Name: DR. BRUCE MICHAEL KRAL
Title or Position: PRESIDENT
Credential:
Phone: 210-824-0152