Provider Demographics
NPI:1629246335
Name:MOLINA, IBIS VANESSA
Entity Type:Individual
Prefix:DR
First Name:IBIS
Middle Name:VANESSA
Last Name:MOLINA
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:IBIS
Other - Middle Name:VANESSA
Other - Last Name:CLYDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19298 STONE OAK PKWY STE 1105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3394
Mailing Address - Country:US
Mailing Address - Phone:210-247-5162
Mailing Address - Fax:
Practice Address - Street 1:19298 STONE OAK PKWY STE 1105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3394
Practice Address - Country:US
Practice Address - Phone:210-247-5162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist