Provider Demographics
NPI:1013113562
Name:SONTORA MAX PA
Entity Type:Organization
Organization Name:SONTORA MAX PA
Other - Org Name:SONTERRA ORAL AND MAXILLOFACIAL SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-494-2005
Mailing Address - Street 1:1202 EAST SONTERRA BLVD
Mailing Address - Street 2:SUITE 801
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TN
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-494-2005
Mailing Address - Fax:210-494-1332
Practice Address - Street 1:1202 EAST SONTERRA BLVD
Practice Address - Street 2:SUITE 801
Practice Address - City:SAN ANTONIO
Practice Address - State:TN
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-494-2005
Practice Address - Fax:210-494-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1972562312OtherNPI PROVIDER
1134188576OtherNPI PROVIDER