Provider Demographics
NPI:1720481278
Name:CULEBRA PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:CULEBRA PEDIATRIC DENTISTRY, PLLC
Other - Org Name:TOTS TO TEENS PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYALA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:210-632-4560
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-0356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8839 CULEBRA ROAD
Practice Address - Street 2:SUITE #105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251
Practice Address - Country:US
Practice Address - Phone:210-660-7123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
TX242551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty