Provider Demographics
NPI:1780013391
Name:MOLINA CLYDE DENTISTRY, PLLC
Entity Type:Organization
Organization Name:MOLINA CLYDE DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:IBIS
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:MOLINA-CLYDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-749-8858
Mailing Address - Street 1:19298 STONE OAK PKWY
Mailing Address - Street 2:SUITE 1105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3393
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19298 STONE OAK PKWY
Practice Address - Street 2:SUITE 1105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3393
Practice Address - Country:US
Practice Address - Phone:210-749-8858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty