Provider Demographics
NPI:1134429129
Name:SERAPIO DE LA ROSA JR, D.D.S., P.C.
Entity type:Organization
Organization Name:SERAPIO DE LA ROSA JR, D.D.S., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERAPIO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA ROSA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-804-2212
Mailing Address - Street 1:7720 JONES MALTSBERGER RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6993
Mailing Address - Country:US
Mailing Address - Phone:210-804-2212
Mailing Address - Fax:210-804-2355
Practice Address - Street 1:7720 JONES MALTSBERGER RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6993
Practice Address - Country:US
Practice Address - Phone:210-804-2212
Practice Address - Fax:210-804-2355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX143931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198199501Medicaid
TX111234402Medicaid