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General NPI Number Information
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NPI Number | 1093475212
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Entity Type | Organization
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Legal Business Name | CRESTA BELLA DENTAL AND BRACES
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Dates
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Enumeration Date | 12/29/2021
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Last Update Date | 12/29/2021
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Provider Practice Location Address
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Address Line | 19787 IH 10 W STE 204
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City | SAN ANTONIO
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State | TX
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Zip | 78257-1695
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Country | US
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Telephone | 210-598-6002
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Fax |
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Provider Business Mailing Address
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Address Line | 19787 IH 10 W STE 204
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City | SAN ANTONIO
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State | TX
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Zip | 78257-1695
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Country | US
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Telephone | 210-598-6002
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. DAVE GOLDWYN JEQUINTO
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Credential | DDS
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Telephone | 210-598-6002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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