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NPI Code Detail

MEDICARE: SOUTHSIDE CHILDREN'S DENTAL CENTER, P.C.

MEDICARE: SOUTHSIDE CHILDREN'S DENTAL CENTER, P.C.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry
21223S0112XOral and Maxillofacial Surgery (Dentist)
31223X0400XOrthodontics and Dentofacial Orthopedics Dentistry
41223P0221XPediatric Dentistry

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2695123OTHERTXUNITED CONCORDIA
3007874OTHERTXDELTA CARE
438644OTHERTXUNITED HEALTHCARE
584D747OTHERTXBLUECROSS

General Provider Information

NPI Number : 1902815335
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHSIDE CHILDREN'S DENTAL CENTER, P.C.
Provider Business Mailing Address
First Line : 125 SW MILITARY DR
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78221-1650
Country : US
Telephone Number : 210-922-3483
Fax Number : 210-922-8902
Provider Business Practice Location Address
First Line : 125 SW MILITARY DR
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78221-1650
Country : US
Telephone Number : 210-922-3483
Fax Number : 210-922-8902
Authorized Official
Title or Position : OFFICE MANAGER
Name : DORIS CODERRE-ZERCHER
Credential :
Telephone Number : 210-922-3483
Provider Enumeration Date : 08/05/2006
Last Update Date : 10/21/2022

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