Provider Demographics
NPI:1366643496
Name:SAN PEDRO DENTAL ASSOCIATES, PC
Entity type:Organization
Organization Name:SAN PEDRO DENTAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-981-9193
Mailing Address - Street 1:16414 SAN PEDRO AVE
Mailing Address - Street 2:#200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2277
Mailing Address - Country:US
Mailing Address - Phone:210-499-0009
Mailing Address - Fax:210-499-0002
Practice Address - Street 1:16414 SAN PEDRO AVE
Practice Address - Street 2:#200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2277
Practice Address - Country:US
Practice Address - Phone:210-499-0009
Practice Address - Fax:210-499-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX170721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty