Provider Demographics
NPI:1710587431
Name:MYSA DENTAL PLLC
Entity Type:Organization
Organization Name:MYSA DENTAL PLLC
Other - Org Name:MYSA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KHUSHBU
Authorized Official - Middle Name:
Authorized Official - Last Name:MALHOTRA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-834-4646
Mailing Address - Street 1:10615 YSAMY WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1659
Mailing Address - Country:US
Mailing Address - Phone:617-834-4646
Mailing Address - Fax:
Practice Address - Street 1:13762 POTRANCO RD STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-4047
Practice Address - Country:US
Practice Address - Phone:210-564-9044
Practice Address - Fax:210-564-9088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYSA DENTAL PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-30
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental