Provider Demographics
NPI:1942519632
Name:TEXAN SMILE DENTISTRY 1 PC
Entity Type:Organization
Organization Name:TEXAN SMILE DENTISTRY 1 PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-681-4867
Mailing Address - Street 1:5858 S PADRE ISLAND DR
Mailing Address - Street 2:#54A
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-3932
Mailing Address - Country:US
Mailing Address - Phone:361-994-4867
Mailing Address - Fax:361-994-1655
Practice Address - Street 1:5858 S PADRE ISLAND DR
Practice Address - Street 2:#54A
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-3932
Practice Address - Country:US
Practice Address - Phone:361-994-4867
Practice Address - Fax:361-994-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX158891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty