Provider Demographics
NPI:1972761450
Name:RALPH A. CREVOISIER D.D.S.,M.S.D. PC
Entity Type:Organization
Organization Name:RALPH A. CREVOISIER D.D.S.,M.S.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:CREVOISIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MSD
Authorized Official - Phone:210-494-4978
Mailing Address - Street 1:14107 COUNTRY VALE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2354
Mailing Address - Country:US
Mailing Address - Phone:210-494-4978
Mailing Address - Fax:
Practice Address - Street 1:8110 WINDWAY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78239-2433
Practice Address - Country:US
Practice Address - Phone:210-653-9227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76631223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX515067495Medicaid