Provider Demographics
NPI:1457565483
Name:ALL ABOUT TEETH
Entity type:Organization
Organization Name:ALL ABOUT TEETH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:ROSHARON
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-545-3929
Mailing Address - Street 1:14400 JONES MALTSBERGER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-3748
Mailing Address - Country:US
Mailing Address - Phone:210-545-3929
Mailing Address - Fax:210-545-5069
Practice Address - Street 1:14400 JONES MALTSBERGER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-3748
Practice Address - Country:US
Practice Address - Phone:210-545-3929
Practice Address - Fax:210-545-5069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD 182051223G0001X
TXD 165141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX18205OtherDR WYRICK'S STATE LIC. #