Provider Demographics
NPI:1114411089
Name:IDEAL DENTAL OF ALAMO RANCH PLLC
Entity Type:Organization
Organization Name:IDEAL DENTAL OF ALAMO RANCH PLLC
Other - Org Name:IDEAL DENTAL OF ALAMO RANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:CANAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-361-0600
Mailing Address - Street 1:PO BOX 840925
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1438
Mailing Address - Country:US
Mailing Address - Phone:972-331-8079
Mailing Address - Fax:
Practice Address - Street 1:12007 ALAMO RANCH PKWY, STE 122
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253
Practice Address - Country:US
Practice Address - Phone:210-504-2953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty