Provider Demographics
NPI:1043541741
Name:INGRAM MALL DENTAL CENTER, P.L.L.C.
Entity Type:Organization
Organization Name:INGRAM MALL DENTAL CENTER, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-354-4867
Mailing Address - Street 1:6301 NW LOOP 410
Mailing Address - Street 2:L1A
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-3824
Mailing Address - Country:US
Mailing Address - Phone:210-354-4867
Mailing Address - Fax:210-681-6985
Practice Address - Street 1:6301 NW LOOP 410
Practice Address - Street 2:L1A
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-3824
Practice Address - Country:US
Practice Address - Phone:210-354-4867
Practice Address - Fax:210-681-6985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty