=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518350727
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARBELLA DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2015
-----------------------------------------------------
Last Update Date | 05/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 791 FM 1103 STE 119
-----------------------------------------------------
City | CIBOLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78108-3673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-625-4815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 791 FM 1103 STE 119
-----------------------------------------------------
City | CIBOLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-625-4815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | NANCY VARGAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-787-4970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------