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General NPI Number Information
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NPI Number | 1538837851
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Entity Type | Organization
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Legal Business Name | WISDOM TEETH RX PLLC
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Dates
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Enumeration Date | 09/01/2021
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Last Update Date | 09/01/2021
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Provider Practice Location Address
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Address Line | 7254 BLANCO RD STE 107
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City | SAN ANTONIO
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State | TX
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Zip | 78216-4930
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Country | US
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Telephone | 210-817-4480
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Fax |
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Provider Business Mailing Address
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Address Line | 4832 TRAIL CREST CIR
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City | AUSTIN
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State | TX
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Zip | 78735-6355
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Country | US
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Telephone | 512-985-7516
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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 | RAHUL MALYA
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Credential | DDS
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Telephone | 512-985-7516
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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