Provider Demographics
NPI:1720158496
Name:MODERN DENTAL PROFESSIONALS SAN ANTONIO PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS SAN ANTONIO PC
Other - Org Name:CASTLE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ERVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-653-4867
Mailing Address - Street 1:8415 DATAPOINT DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3298
Mailing Address - Country:US
Mailing Address - Phone:714-578-6358
Mailing Address - Fax:
Practice Address - Street 1:17700 SAN PEDRO AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1404
Practice Address - Country:US
Practice Address - Phone:210-495-6255
Practice Address - Fax:210-495-6260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20569122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty