=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295161818
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDS WORLD PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2013
-----------------------------------------------------
Last Update Date | 09/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20711 WILDERNESS OAK SUTE 103
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-2640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-787-1200
-----------------------------------------------------
Fax | 210-497-6077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20711 WILDERNESS OAK SUTE 103
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-2640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-787-1200
-----------------------------------------------------
Fax | 210-497-6077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. MARIELENA TORRES-RICART
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 210-787-1200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 26456
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------