Provider Demographics
NPI:1669011235
Name:KUSOM PEDIATRIC DENTAL SOUTH PLLC
Entity Type:Organization
Organization Name:KUSOM PEDIATRIC DENTAL SOUTH PLLC
Other - Org Name:GREAT KIDS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:DUTTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-888-0700
Mailing Address - Street 1:18707 HARDY OAK BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4895
Mailing Address - Country:US
Mailing Address - Phone:210-888-0700
Mailing Address - Fax:210-625-7398
Practice Address - Street 1:1134 CULEBRA RD STE 109
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-6080
Practice Address - Country:US
Practice Address - Phone:210-888-0700
Practice Address - Fax:210-625-7398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-31
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty