Provider Demographics
NPI:1265442362
Name:M M ORTHODONTICS PA
Entity Type:Organization
Organization Name:M M ORTHODONTICS PA
Other - Org Name:M & M ORTHODONTICS, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:T
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:210-670-9000
Mailing Address - Street 1:9530 POTRANCO RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-9601
Mailing Address - Country:US
Mailing Address - Phone:210-670-9000
Mailing Address - Fax:210-670-9100
Practice Address - Street 1:9530 POTRANCO RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-9601
Practice Address - Country:US
Practice Address - Phone:210-670-9000
Practice Address - Fax:210-670-9100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204021223X0400X
TX210861223X0400X
TX239831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174951701Medicaid
TX1312131OtherUNITED CONCORDIA
TX142539904Medicaid
TX142539906Medicaid
TX174952501Medicaid