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General NPI Number Information
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NPI Number | 1720481278
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Entity Type | Organization
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Legal Business Name | CULEBRA PEDIATRIC DENTISTRY, PLLC
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Dates
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Enumeration Date | 09/29/2014
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Last Update Date | 09/29/2014
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Provider Practice Location Address
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Address Line | 8839 CULEBRA ROAD SUITE #105
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City | SAN ANTONIO
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State | TX
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Zip | 78251
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Country | US
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Telephone | 210-660-7123
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 356
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City | LYTLE
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State | TX
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Zip | 78052-0356
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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 | PRESIDENT
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Name | DR. 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 | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #2
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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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