Provider Demographics
NPI:1093817421
Name:SAN MARCOS ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:SAN MARCOS ORTHODONTICS PLLC
Other - Org Name:SERRANO & KYGER ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:A
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-899-1633
Mailing Address - Street 1:800 W. CHANDLER BLVD
Mailing Address - Street 2:STE 5
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-2508
Mailing Address - Country:US
Mailing Address - Phone:480-899-1633
Mailing Address - Fax:480-786-3647
Practice Address - Street 1:800 W. CHANDLER BLVD
Practice Address - Street 2:STE 5
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-2508
Practice Address - Country:US
Practice Address - Phone:480-899-1633
Practice Address - Fax:480-786-3647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD28141223X0400X
AZD46901223X0400X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6403960001Medicare NSC