Provider Demographics
NPI:1245648732
Name:GERIATRIC DENTAL GROUP OF SOUTH TEXAS, PA
Entity type:Organization
Organization Name:GERIATRIC DENTAL GROUP OF SOUTH TEXAS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:DIRKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-617-4446
Mailing Address - Street 1:5282 MEDICAL DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4983
Mailing Address - Country:US
Mailing Address - Phone:210-617-4446
Mailing Address - Fax:210-617-5572
Practice Address - Street 1:5282 MEDICAL DR STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4983
Practice Address - Country:US
Practice Address - Phone:210-617-4446
Practice Address - Fax:210-617-5572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16152261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental