Healthcare Provider Details

I. General information

NPI: 1083089270
Provider Name (Legal Business Name): BULVERDE PREMIER DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20540 HIGHWAY 46 W STE 100
SPRING BRANCH TX
78070-6825
US

IV. Provider business mailing address

20540 HIGHWAY 46 W STE 100
SPRING BRANCH TX
78070-6825
US

V. Phone/Fax

Practice location:
  • Phone: 830-980-8099
  • Fax:
Mailing address:
  • Phone: 830-980-8099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateTX

VIII. Authorized Official

Name: MRS. BETHANY ENDERLE
Title or Position: PRACTICE DIRECTOR
Credential:
Phone: 830-980-8099