Provider Demographics
NPI:1699181578
Name:VILLA DENTAL, PLLC
Entity Type:Organization
Organization Name:VILLA DENTAL, PLLC
Other - Org Name:VILLA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMANUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:STAES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-810-2760
Mailing Address - Street 1:6215 VIA LA CANTERA APT 331
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78256-2537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1546 BABCOCK RD
Practice Address - Street 2:STE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4724
Practice Address - Country:US
Practice Address - Phone:504-810-2760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-11
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28289261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1336495738Medicaid