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General NPI Number Information
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NPI Number | 1346651478
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Entity Type | Organization
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Legal Business Name | MOBILE DENTAL MANAGEMENT, LLC
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Dates
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Enumeration Date | 05/12/2014
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Last Update Date | 05/12/2014
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Provider Practice Location Address
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Address Line | 1813 GRANDSTAND DR
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City | SAN ANTONIO
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State | TX
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Zip | 78238-4701
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Country | US
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Telephone | 210-569-2650
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Fax |
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Provider Business Mailing Address
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Address Line | 926 WINDMILL PALM
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City | SAN ANTONIO
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State | TX
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Zip | 78216-8004
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Country | US
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Telephone | 210-569-2650
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | PEGEEN MOIRA KRAMER
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Credential | MBA, MED
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Telephone | 210-569-2650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12325
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6593
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License Number State | TX
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