Provider Demographics
NPI: | 1548579386 |
---|---|
Name: | ADVANCED SMILE CARE, LLC |
Entity Type: | Organization |
Organization Name: | ADVANCED SMILE CARE, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRACTICE ADMINISTRATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOS |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SELIG |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 210-366-3606 |
Mailing Address - Street 1: | 11874 WURZBACH RD |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN ANTONIO |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 78230-2744 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 210-366-3606 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3829 LOCKHILL SELMA RD STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | SAN ANTONIO |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78230-1762 |
Practice Address - Country: | US |
Practice Address - Phone: | 210-366-3606 |
Practice Address - Fax: | 210-366-0052 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-09-28 |
Last Update Date: | 2019-01-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |