Provider Demographics
NPI:1659895316
Name:ROYAL-PRIEST, KSENIA LEONIDOVNA (DMD, MS)
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:LEONIDOVNA
Last Name:ROYAL-PRIEST
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10103 W LOOP 1604 N STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-9716
Mailing Address - Country:US
Mailing Address - Phone:210-495-2000
Mailing Address - Fax:
Practice Address - Street 1:10730 POTRANCO RD STE 111
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-3330
Practice Address - Country:US
Practice Address - Phone:210-495-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX333171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice