Provider Demographics
NPI:1194494708
Name:DEZAVALA DENTAL AND BRACES PLLC
Entity type:Organization
Organization Name:DEZAVALA DENTAL AND BRACES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OLMOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-268-3384
Mailing Address - Street 1:4519 DEZAVALA ROAD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249
Mailing Address - Country:US
Mailing Address - Phone:210-690-9221
Mailing Address - Fax:
Practice Address - Street 1:4519 DEZAVALA ROAD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249
Practice Address - Country:US
Practice Address - Phone:210-690-9221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-08
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty