Provider Demographics
NPI:1033765094
Name:NORTHEAST CHILDREN'S DENTISTRY, INC
Entity Type:Organization
Organization Name:NORTHEAST CHILDREN'S DENTISTRY, INC
Other - Org Name:NORTHEAST CHILDREN'S DENTISTRY-DOMINION CROSSING LOCATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-654-6882
Mailing Address - Street 1:21727 IH 10 W STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-2107
Mailing Address - Country:US
Mailing Address - Phone:210-314-4545
Mailing Address - Fax:
Practice Address - Street 1:21727 IH 10 W STE 203
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-2107
Practice Address - Country:US
Practice Address - Phone:210-314-4545
Practice Address - Fax:210-314-4596
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST CHILDREN'S DENTISTRY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00K78OtherBLUE CROSS BLUE SHIELD