Provider Demographics
NPI:1346780566
Name:XLNT DENTAL PLLC
Entity Type:Organization
Organization Name:XLNT DENTAL PLLC
Other - Org Name:GRAVIS & RILEY FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELA MARIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:PUNZALAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-970-9158
Mailing Address - Street 1:3130 CANAVERAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-4007
Mailing Address - Country:US
Mailing Address - Phone:210-970-9158
Mailing Address - Fax:
Practice Address - Street 1:504 E GRAVIS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:TX
Practice Address - Zip Code:78384-2708
Practice Address - Country:US
Practice Address - Phone:201-970-9158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX307781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty