Provider Demographics
NPI:1689220451
Name:NORTHEAST CHILDREN'S DENTISTRY, INC
Entity Type:Organization
Organization Name:NORTHEAST CHILDREN'S DENTISTRY, INC
Other - Org Name:NORTHEAST CHILDREN'S DENTISTRY- NORTHERN OAKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-654-6882
Mailing Address - Street 1:4358 THOUSAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-2102
Mailing Address - Country:US
Mailing Address - Phone:210-656-4300
Mailing Address - Fax:210-656-4302
Practice Address - Street 1:4358 THOUSAND OAKS DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-2102
Practice Address - Country:US
Practice Address - Phone:210-656-4300
Practice Address - Fax:210-656-4302
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST CHILDREN'S DENTISTRY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00K78OtherBLUE CROSS BLUE SHIELD