Provider Demographics
NPI:1902208648
Name:NAUTICAL DENTAL
Entity Type:Organization
Organization Name:NAUTICAL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-671-0265
Mailing Address - Street 1:16414 SAN PEDRO AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2277
Mailing Address - Country:US
Mailing Address - Phone:210-499-0009
Mailing Address - Fax:210-499-0003
Practice Address - Street 1:16414 SAN PEDRO AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2277
Practice Address - Country:US
Practice Address - Phone:210-499-0009
Practice Address - Fax:210-499-0003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ERIC D. CORNELIUS DDS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28732122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty