Provider Demographics
NPI:1902815335
Name:SOUTHSIDE CHILDREN'S DENTAL CENTER, P.C.
Entity Type:Organization
Organization Name:SOUTHSIDE CHILDREN'S DENTAL CENTER, P.C.
Other - Org Name:SCOTT HEBERT DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CODERRE-ZERCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-922-3483
Mailing Address - Street 1:125 SW MILITARY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-1650
Mailing Address - Country:US
Mailing Address - Phone:210-922-3483
Mailing Address - Fax:210-922-8902
Practice Address - Street 1:125 SW MILITARY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78221-1650
Practice Address - Country:US
Practice Address - Phone:210-922-3483
Practice Address - Fax:210-922-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126722102Medicaid
TX695123OtherUNITED CONCORDIA
TX007874OtherDELTA CARE
TX38644OtherUNITED HEALTHCARE
TX84D747OtherBLUECROSS