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General NPI Number Information
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NPI Number | 1366848129
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Entity Type | Organization
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Legal Business Name | KERRVILLE PEDIATRIC DENTISTRY, PLLC
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Dates
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Enumeration Date | 11/06/2014
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Last Update Date | 11/06/2014
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Provider Practice Location Address
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Address Line | 1700 SIDNEY BAKER ST SUITE #200
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City | KERRVILLE
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State | TX
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Zip | 78028-2654
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Country | US
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Telephone | 210-632-4560
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Fax |
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Provider Business Mailing Address
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Address Line | 12016 EUCALYPTUS ST
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City | SAN ANTONIO
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State | TX
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Zip | 78245-3307
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JOANNA AYALA
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Credential | D.M.D.
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Telephone | 210-632-4560
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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 | 24255
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License Number State | TX
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