Provider Demographics
NPI:1245252238
Name:NORTHEAST CHILDREN'S DENTISTRY, INC
Entity type:Organization
Organization Name:NORTHEAST CHILDREN'S DENTISTRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-654-6882
Mailing Address - Street 1:8606 VILLAGE DR
Mailing Address - Street 2:STE. B
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5506
Mailing Address - Country:US
Mailing Address - Phone:210-654-6882
Mailing Address - Fax:210-654-0036
Practice Address - Street 1:8606 VILLAGE DR
Practice Address - Street 2:STE. B
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5506
Practice Address - Country:US
Practice Address - Phone:210-654-6882
Practice Address - Fax:210-654-0036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00K78VOtherBLUE CROSS BLUE SHIELD