=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578163390
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATASCOSA DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2020
-----------------------------------------------------
Last Update Date | 04/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 W GOODWIN ST
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78064-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-569-4746
-----------------------------------------------------
Fax | 830-281-4700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24200 IH 10 W STE 112
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78257-1150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-687-1133
-----------------------------------------------------
Fax | 210-687-1132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JANELLE BAYS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 808-646-1833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------