Provider Demographics
NPI:1841714672
Name:SAN ANTONIO ENDODONTICS ASSOCIATES LLC
Entity type:Organization
Organization Name:SAN ANTONIO ENDODONTICS ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:CLOUTIER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:210-341-8281
Mailing Address - Street 1:1100 NW LOOP 410 STE 515
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-2259
Mailing Address - Country:US
Mailing Address - Phone:210-341-8281
Mailing Address - Fax:210-341-8282
Practice Address - Street 1:1110 NW LOOP 410
Practice Address - Street 2:SUITE 515
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213
Practice Address - Country:US
Practice Address - Phone:210-341-8281
Practice Address - Fax:210-341-8282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX264121223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty