Provider Demographics
NPI:1104475185
Name:DE ZAVALA MODERN DENTISTRY, PC
Entity type:Organization
Organization Name:DE ZAVALA MODERN DENTISTRY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENAVIDES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-740-0645
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8206
Mailing Address - Fax:303-952-0892
Practice Address - Street 1:5215 DE ZAVALA RD STE 103
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2985
Practice Address - Country:US
Practice Address - Phone:210-740-0645
Practice Address - Fax:210-757-4067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty