Provider Demographics
NPI:1417006065
Name:ALAMO MAXILLOFACIAL SURGICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:ALAMO MAXILLOFACIAL SURGICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHY
Authorized Official - Suffix:
Authorized Official - Credentials:MHSM
Authorized Official - Phone:210-614-3915
Mailing Address - Street 1:4499 MEDICAL DR
Mailing Address - Street 2:SUITE #190
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3735
Mailing Address - Country:US
Mailing Address - Phone:210-614-3915
Mailing Address - Fax:210-614-3918
Practice Address - Street 1:4499 MEDICAL DR
Practice Address - Street 2:SUITE #190
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3735
Practice Address - Country:US
Practice Address - Phone:210-614-3915
Practice Address - Fax:210-614-3918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0014AWOtherMEDICARE
TX079997501Medicaid