Provider Demographics
NPI:1508156589
Name:KIDDO DENTAL PA
Entity Type:Organization
Organization Name:KIDDO DENTAL PA
Other - Org Name:CESAR ROTTER DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-459-6800
Mailing Address - Street 1:20306 ENCINO LEDGE STE 106
Mailing Address - Street 2:KIDDO DENTAL
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259
Mailing Address - Country:US
Mailing Address - Phone:210-495-6800
Mailing Address - Fax:210-495-6801
Practice Address - Street 1:20306 ENCINO LEDGE STE 106
Practice Address - Street 2:KIDDO DENTAL
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259
Practice Address - Country:US
Practice Address - Phone:210-495-6800
Practice Address - Fax:210-495-6801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182604207Medicaid