Provider Demographics
NPI:1649634007
Name:IDEAL DENTAL OF ROAD RUNNER PLLC
Entity type:Organization
Organization Name:IDEAL DENTAL OF ROAD RUNNER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SULMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-361-0600
Mailing Address - Street 1:8338 N LOOP 1604 W
Mailing Address - Street 2:BUILDING 1 STE 104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3481
Mailing Address - Country:US
Mailing Address - Phone:210-877-9100
Mailing Address - Fax:
Practice Address - Street 1:8338 N LOOP 1604 W
Practice Address - Street 2:BUILDING 1 STE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3481
Practice Address - Country:US
Practice Address - Phone:210-877-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty