Provider Demographics
NPI:1942518626
Name:DEERFIELD DENTAL
Entity Type:Organization
Organization Name:DEERFIELD DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:KIANSKY
Authorized Official - Last Name:BLAESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-445-7915
Mailing Address - Street 1:5999 DE ZAVALA RD STE 122
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2236
Mailing Address - Country:US
Mailing Address - Phone:210-408-6000
Mailing Address - Fax:210-561-2599
Practice Address - Street 1:14855 BLANCO RD STE 413
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7731
Practice Address - Country:US
Practice Address - Phone:210-408-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19006122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty