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General NPI Number Information
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NPI Number | 1104209535
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Entity Type | Organization
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Legal Business Name | MANZANITA KIDS DENTISTRY & ORTHODONTICS, PLLC
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Dates
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Enumeration Date | 07/02/2015
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Last Update Date | 06/09/2025
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Provider Practice Location Address
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Address Line | 11800 DESSAU RD SUITE 203
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City | AUSTIN
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State | TX
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Zip | 78754-2154
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Country | US
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Telephone | 210-884-5750
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Fax |
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Provider Business Mailing Address
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Address Line | 11800 DESSAU RD STE 203
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City | AUSTIN
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State | TX
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Zip | 78754-2187
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Country | US
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Telephone | 512-490-1212
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. GLORIA YANEZ
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Credential | D.D.S., M.S.
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Telephone | 210-884-5750
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 21450
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License Number State | TX
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