Provider Demographics
NPI:1154653004
Name:SUNRISE MALL DENTAL CENTER, P.L.L.C.
Entity Type:Organization
Organization Name:SUNRISE MALL DENTAL CENTER, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-354-4867
Mailing Address - Street 1:5858 S PADRE ISLAND DR
Mailing Address - Street 2:54A
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-3932
Mailing Address - Country:US
Mailing Address - Phone:361-994-4867
Mailing Address - Fax:210-994-1655
Practice Address - Street 1:5858 S PADRE ISLAND DR
Practice Address - Street 2:54A
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-3932
Practice Address - Country:US
Practice Address - Phone:361-994-4867
Practice Address - Fax:210-994-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty