Provider Demographics
NPI:1750032504
Name:SAN MARCOS PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type:Organization
Organization Name:SAN MARCOS PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:512-353-5500
Mailing Address - Street 1:1330 WONDER WORLD DR STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7567
Mailing Address - Country:US
Mailing Address - Phone:512-353-5500
Mailing Address - Fax:512-353-1619
Practice Address - Street 1:1330 WONDER WORLD DR STE 103
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7567
Practice Address - Country:US
Practice Address - Phone:512-353-5500
Practice Address - Fax:512-353-1619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty