Provider Demographics
NPI:1841459310
Name:HIGHLAND FAMILY DENTISTRY
Entity type:Organization
Organization Name:HIGHLAND FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:R
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-337-6834
Mailing Address - Street 1:3601 LEADVILLE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-6938
Mailing Address - Country:US
Mailing Address - Phone:512-965-0663
Mailing Address - Fax:
Practice Address - Street 1:3630 SE MILITARY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-4050
Practice Address - Country:US
Practice Address - Phone:210-337-6834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0094708-03Medicaid
TX164291001Medicaid