=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649607003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYTLE PEDIATRIC DENTISTRY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2013
-----------------------------------------------------
Last Update Date | 02/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19315 MCDONALD ST
-----------------------------------------------------
City | LYTLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78052-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-772-5600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 356
-----------------------------------------------------
City | LYTLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | JOANNA AYALA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-632-4560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 24255
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------