Provider Demographics
NPI:1093475212
Name:CRESTA BELLA DENTAL AND BRACES
Entity Type:Organization
Organization Name:CRESTA BELLA DENTAL AND BRACES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:GOLDWYN
Authorized Official - Last Name:JEQUINTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-598-6002
Mailing Address - Street 1:19787 IH 10 W STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1695
Mailing Address - Country:US
Mailing Address - Phone:210-598-6002
Mailing Address - Fax:
Practice Address - Street 1:19787 IH 10 W STE 204
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-1695
Practice Address - Country:US
Practice Address - Phone:210-598-6002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental