Provider Demographics
NPI:1558824201
Name:CELEBRACES SAN PEDRO LLC
Entity Type:Organization
Organization Name:CELEBRACES SAN PEDRO LLC
Other - Org Name:CELEBRATE DENTAL & BRACES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS CAGS
Authorized Official - Phone:210-675-7000
Mailing Address - Street 1:6868 SAN PEDRO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-7201
Mailing Address - Country:US
Mailing Address - Phone:210-675-7000
Mailing Address - Fax:
Practice Address - Street 1:6868 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7201
Practice Address - Country:US
Practice Address - Phone:210-675-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-10
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty