Provider Demographics
NPI: | 1952174120 |
---|---|
Name: | FULL SMILE HELOTES ORTHODONTICS, PLLC |
Entity Type: | Organization |
Organization Name: | FULL SMILE HELOTES ORTHODONTICS, PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CREDENTIALING MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JENNIFER |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | WILLIAMS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 806-353-1055 |
Mailing Address - Street 1: | 11330 POTRANCO RD STE 105 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN ANTONIO |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 78253-7282 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 210-695-1738 |
Mailing Address - Fax: | 210-695-1736 |
Practice Address - Street 1: | 11868 BANDERA RD |
Practice Address - Street 2: | |
Practice Address - City: | HELOTES |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78023-4132 |
Practice Address - Country: | US |
Practice Address - Phone: | 210-695-1738 |
Practice Address - Fax: | 210-695-1736 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2023-10-31 |
Last Update Date: | 2023-10-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223X0400X | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | Group - Single Specialty |