Provider Demographics
NPI:1346651478
Name:MOBILE DENTAL MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MOBILE DENTAL MANAGEMENT, LLC
Other - Org Name:KEEN DENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PEGEEN
Authorized Official - Middle Name:MOIRA
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, MED
Authorized Official - Phone:210-569-2650
Mailing Address - Street 1:926 WINDMILL PALM
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-8004
Mailing Address - Country:US
Mailing Address - Phone:210-569-2650
Mailing Address - Fax:
Practice Address - Street 1:1813 GRANDSTAND DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-4701
Practice Address - Country:US
Practice Address - Phone:210-569-2650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123251223G0001X
TX65931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167017602Medicaid
TX120877902Medicaid