Provider Demographics
NPI:1114154952
Name:ROSA MORA D.D.S
Entity Type:Organization
Organization Name:ROSA MORA D.D.S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-583-5050
Mailing Address - Street 1:921 E MAIN AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78573
Mailing Address - Country:US
Mailing Address - Phone:956-583-5050
Mailing Address - Fax:956-583-5067
Practice Address - Street 1:921 E MAIN AVE
Practice Address - Street 2:SUITE2
Practice Address - City:ALTON
Practice Address - State:TX
Practice Address - Zip Code:78573-0952
Practice Address - Country:US
Practice Address - Phone:956-583-5050
Practice Address - Fax:956-583-5067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20419122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151616301Medicaid