=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861910341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTORIA KIDS DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 PROFESSIONAL PARK DR
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77904-2351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-578-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 PROFESSIONAL PARK DR
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77904-2351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-578-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MS. AMANDA SAIZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 254-338-1468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------