Provider Demographics
NPI:1255348926
Name:M M ORTHODONTICS PA
Entity type:Organization
Organization Name:M M ORTHODONTICS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:T
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:210-696-3001
Mailing Address - Street 1:4422 DE ZAVALA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2013
Mailing Address - Country:US
Mailing Address - Phone:210-696-3001
Mailing Address - Fax:210-764-1989
Practice Address - Street 1:4422 DE ZAVALA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2013
Practice Address - Country:US
Practice Address - Phone:210-696-3001
Practice Address - Fax:210-764-1989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210861223X0400X
TX204021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1312131OtherUNITED CONCORDIA DENTAL
TX174951703Medicaid
TX142539903Medicaid
TX174952503Medicaid
TX0014940OtherFACILITY NUMBER
TX142539908Medicaid