Provider Demographics
NPI:1619602414
Name:PENDLETON, ISHMAEL
Entity Type:Individual
Prefix:
First Name:ISHMAEL
Middle Name:
Last Name:PENDLETON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20710 HUEBNER RD APT 3209
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-2540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2940 STANLEY RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-2740
Practice Address - Country:US
Practice Address - Phone:210-295-4156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist