Provider Demographics
NPI:1043642994
Name:CELEBRACES MARBACH
Entity Type:Organization
Organization Name:CELEBRACES MARBACH
Other - Org Name:CELEBRATE DENTAL & BRACES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, CAGS
Authorized Official - Phone:210-675-7000
Mailing Address - Street 1:8700 MARBACH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-2345
Mailing Address - Country:US
Mailing Address - Phone:210-675-7000
Mailing Address - Fax:210-675-7005
Practice Address - Street 1:8700 MARBACH RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-2345
Practice Address - Country:US
Practice Address - Phone:210-675-7000
Practice Address - Fax:210-675-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205340703Medicaid